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^ABORTION 

A^D  ITS  TREATMENT,  FROM  THE  STAND-POmi 
OF  PRACTICAL  EXPERIENCE 


A  SPECIAL  COURSE  OF  LECTURES  DELIVERED  AT 

THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS,  NEW  YORK 

SESSION  OF  1889-"90 


BY 

T.    GAILLAED   THOMAS,  M.  D. 

EMERITUS    PROFESSOR    OF    OBSTETRICS    A>'D    GYNECOLOGY 


FROM  NOTES 

By  p.  BRYXBERG  PORTER,  M.  D. 

REVISED  BY  THE  AUTHOR 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1896 


^ 


iA 


Copyright,  1890, 
By  D.  APPLETON  and  COMPANY. 


ABORTION  AND   ITS   TREATMENT. 


LECTURE  I. 

Vagueness  and  diversity  of  opinion  in  reference  to  the  subject — 
The  views  here  expressed  based  on  practical  experience — 
The  importance  of  the  uterus  in  the  female  economy — Im- 
pregnation and  conception — The  development  of  the  em- 
bryo— Formation  of  the  placenta — Definition  of  abortion — 
Distinction  between  abortion,  miscarriage,  and  premature 
labor — The  natural  history  of  abortion — Differences  in  the 
way  abortion  may  occur  and  the  necessity  of  treating  each 
ease  according  to  its  individual  character  and  circum- 
stances. 

Gentlemen  :  I  have  selected  abortion  as  the 
subject  for  this  special  course  of  lectures,  and  I 
shall  treat  it  entirely  from  a  practical  point  of 
view.  I  have  chosen  this  topic  for  the  reason 
that,  as  I  look  back  over  my  experience  in  the 
medical  profession — a  career  of  now  more  than 
thirty-five  years — T  recall  nothing  which  in 
times  past  has  caused  me   more  anxiety  and 


2  ABORTION  AND  ITS  TREATMENT. 

doabt,  or  in  regard  to  which  I  have  found  it 
more  difficult  to  get  any  satisfactory  rules  from 
books,  than  the  treatment  of  abortion.  When 
you  come  to  look  for  absolute  rules  in  the  vari- 
ous authorities  on  obstetrics,  you  will  find  a 
great  deal  of  uncertainty  and  diversity  of  opin- 
ion. Only  recently  a  discussion  took  place  on 
this  subject  in  a  public  society  in  this  country  ; 
and  here,  again,  in  reading  the  reports  of  it 
published  in  the  medical  journals,  one  is  at 
once  struck  with  the  want  of  unanimity  among 
the  different  participants. 

I  want  you  to  understand  clearly  that  in 
these  lectures  I  am  not  going  to  give  you  the 
opinions  of  the  latest  authorities  in  Vienna, 
London,  or  Paris,  but  that  I  will  impart  to  you 
all  that  a  thirty-five  years'  practice  has  taught 
me  about  abortion.  To  give  the  results  derived 
from  such  a  practical  experience  is,  as  I  con- 
ceive, and  as  I  have  often  had  occasion  to  re- 
mark in  my  lectures,  the  most  useful  kind  of 
teaching,  as  such  instruction  will  enable  the 
pupil  to  commence  in  his  practice  at  the  point 


ABORTIOX  AND  ITS  TREATMENT.  3 

where  Ms  teacher  left  off.  There  is  a  vast  dif- 
ference between  learning  and  being  taught  a 
thing.  If  yoTi  have  to  learn  anything  from 
your  own  experience,  it  may  take  you  a  long 
time  and  involve  a  waste  of  much  honest  effort ; 
but  if  you  are  taught  it  at  the  beginning  by 
one  who  has  thoroughly  studied  the  subject 
and  had  much  personal  experience  in  regard 
to  it,  you  can  readily  perceive  at  how  great  an 
advantage  this  places  you. 

The  uterus  is  a  most  extraordinary  part  of 
the  female  economy.  It  is  the  organ  which 
divides  one  sex  from  the  other.  This  organ  has 
three  entirely  distinct  and  different  periods  of 
existence.  From  birth  to  the  age  of  thirteen, 
or  puberty,  it  is  undeveloped  and  unimpor- 
tant. From  thirteen  to  fifty  its  career  is  one  of 
intense  activity,  and  it  has  a  marked  influence 
upon  the  whole  being  of  the  woman.  From 
the  age  of  about  fifty  to  the  close  of  life  it 
sinks  into  insignificance  again,  and  becomes  an 
atrophied  and  unimportant  organ  —  of  no  use 
whatever. 


4  ABORTION  AND  ITS  TREATMENT. 

Not  only  has  the  uterus  these  different 
phases,  it  is  subject  to  various  distinct  influ- 
ences, and  one  of  the  most  important  of  these  is 
ovulation.  Without  taking  up  any  of  the  moot 
questions  in  regard  to  this  function,  I  will  merely 
say  that  it  certainly  affects  the  uterus  by  caus- 
ing active  congestion  and  haemorrhage.  A  still 
more  marked  influence,  however,  is  excited  by 
the  meeting  of  the  zoosperm  and  ovule  in  some 
part  of  the  uterine  tract.  This  meeting  may 
take  place  in  the  peritonseum,  the  fimbriated 
extremity  of  the  Fallopian  tube  failing  to  grasp 
the  ovum,  and  thus  permitting  it  to  drop  into 
the  abdominal  cavity.  !N"ext,  it  may  occur  in 
the  ovary,  next  in  some  part  of  the  Fallopian 
tube,  and  next  in  the  uterine  cavity.  Lastly, 
it  is  probable  that  it  may  take  place  in  the 
cervical  canal.  Impregnation  and  conception, 
it  should  be  understood,  are  two  entirely  dif- 
ferent things.  Ova  may  become  impregnated 
twelve  times  a  year,  and  yet  conception  may 
not  result.  Conception  is  the  fixation  of  the 
impregnated  ovum,  and  instantaneously  on  its 


ABORTION  AND  ITS  TREATMENT.  5 

occurrence  a  commuiiication  is  set  up  through 
the  nervous  system,  while  the  whole  economy 
of  the  woman  begins  to  change.  In  the  uterus 
the  muscular  fibres  commence  to  grow,  and  the 
mucous  membrane  undergoes  rapid  develop- 
ment. Formerly  many  authorities  held  that  the 
non-pregnant  uterus  had  no  mucous  membrane ; 
but  the  microscopic  researches  of  recent  times 
have  demonstrated  its  existence. 

I  do  not  propose  to  give  you  a  disquisition 
on  generation  and  embryology ;  but  there  are 
a  few  essential  points  with  which  it  is  quite 
necessary  that  you  should  be  familiar  if  you 
wish  to  comprehend  the  subject  of  abortion. 
After  conception  has  taken  place  the  whole  of 
the  mucous  membrane  becomes  thickened,  form- 
ing the  decidua  i^era,  while  a  portion  of  it 
grows  upward  around  the  ovum.  In  olden 
times  it  was  supposed  that  the  latter  was  a 
false  membrane,  but  more  careful  investigations 
proved  that  this  was  not  the  case,  and  that  it 
was  merely  a  hyperplasia  of  the  membrane  in 
this  part.     The  ovum  having  attached  itself  to 


6  ABORTION  AND  ITS  TREATMENT. 

one  particular  spot,  the  exuberant  mucous  mem 
brane  goes  on  growing  about  it  until  it  entirely 
surrounds  it,  and  this  enveloping  membrane  is 
still  known  by  the  old  name  decidua  rejlexa. 
You  have  all  seen  the  bark  of  an  oak  growing 
over  and  covering  a  nail  driven  into  the  tree. 
Thus  it  is  with  the  ovum  and  the  uterine 
mucous  membrane. 

In  a  little  while  the  allantois  is  developed, 
and  from  the  foetal  body,  which  has  no  connec- 
tion with  the  decidua  vera  and  decidua  reflexa, 
two  distinct  membranes  are  formed — the  amnion 
and  the  chorion.  The  latter  attaches  itself  to 
the  uterus  by  little  rootlets  which  extend  into 
the  uterine  glands,  while  the  amnion  is  merely 
a  membrane  which  secretes  a  clear  fluid  known 
as  the  liquor  amnii.  The  foetal  ball  is  every- 
where attached  to  the  uterine  walls,  and  it  gets 
its  nourishment  from  the  carpet-like  surface  of 
the  uterus.  By  endosmosis  the  nutrient  mate- 
rials in  the  blood  of  the  mother  are  taken  into 
the  circulation  of  the  foetus ;  and  not  only  does 
the  chorion  take  nutriment  from  the  mother's 


ABORTION  AND  ITS  TREATMENT.  7 

blood,  but  it  will  also  take  poisons  or  whatever 
else  happens  to  be  circulating  in  it.  Thus,  the 
foetus  may  be  fatally  affected  by  the  hypo- 
dermic injection  of  morphine  or  other  poisons 
into  the  mother's  body. 

The  foetus  is  nourished  in  this  way  until  the 
end  of  the  second  month,  when  a  change  takes 
place.  The  placenta  begins  to  form  ;  and  this 
is  a  vital  point  in  the  subject  of  these  lectures. 
Up  to  two  and  a  half  months  there  is  no  pla- 
centa, so  far  as  abortion  is  concerned.  Between 
two  and  a  half  and  three  and  a  half  months 
the  chorion  loses  all  its  tufts  except  at  one 
point.  Here  it  becomes  excessively  vascular 
and  increased  in  thickness,  and  this  thickened 
portion,  with  the  thickened  decidua,  forms  the 
placenta.  The  rest  of  the  chorion  becomes 
bald,  but  is  still  lightly  attached  to  the  de- 
cidua reflexa.  From  the  third  month  the  pla- 
centa is  the  all-important  element  as  regards 
abortion. 

Abortion  is  to  be  defined  as  the  premature 
casting  off  of  the  product  of  conception  before 


8  ABORTION  AND  ITS  TREATMENT. 

the  end  of  the  fourth  month.  After  the  end 
of  the  fourth  month  the  physiological  condi- 
tions present  are  materially  different.  The  term 
premature  labor  can  not  be  applied  to  expulsion 
of  the  foetus  as  early  as  the  fifth  month.  Au- 
thorities do  not  agree  as  to  how  it  is  best  to 
designate  such  cases  occurring  between  the 
fourth  and  seventh  months.  I  know  of  no  bet- 
ter term  for  them  than  miscarriage.  After  the 
end  of  the  sixth  month  we  style  it  premature 
labor,  because  there  is  a  possibility  of  the  via- 
bility of  the  foetus.  I  would  say  incidentally 
that  I  often  induce  premature  labor,  and  I  re- 
gard it  as  a  procedure  of  the  greatest  possible 
importance.  With  the  experience  which  we 
now  have,  it  can  only  be  regarded  as  trifling 
with  a  woman's  life  to  allow  her  to  go  to  full 
term  in  cases  of  aggravated  albuminuria  from 
puerperal  nephritis,  and  also  in  many  cases  of 
placenta  prsevia. 

In  abortion  we  have  the  expulsion  of  the 
product  of  conception  before  the  end  of  the 
fourth  month,  in  miscarriage  between  the  end 


\  ABORTION  AND  ITS  TREATMENT.  9 

of  the  fourth  month  and  the  end  of  the  sixth 
month,  and  in  premature  labor  between  the  end 
of  the  sixth  and  the  end  of  the  ninth  month. 
A  labor  is  not  regarded  as  strictly  premature, 
however,  which  occurs  within  two  weeks  of  the 
normal  termination  of  gestation.  On  account 
of  the  difference  in  the  physiological  conditions 
at  these  several  periods,  as  I  have  said,  the 
rules  of  treatment  are  also  entirely  different. 
For  example,  while  it  is  perfectly  proper  to 
use  the  tampon  in  the  earlier  months  of  preg- 
nancy, such  a  procedure  might  be  followed  by 
the  most  serious  consequences  during  the  sixth 
month. 

We  come  now  to  consider  the  pathology  and 
natural  history  of  abortion.  When  this  acci- 
dent occurs,  one  of  several  things  may  take 
place.  First,  there  may  be  a  complete  empty- 
ing of  the  uterine  cavity.  A  woman  makes 
some  unusual  exertion  or  becomes  suddenly 
alarmed  from  some  cause  or  other,  and  imme- 
diately there  is  a  violent  and  instantaneous  con- 
traction of  the  uterus,  which  forthwith  expels 


10  ABORTION  AND  ITS  TREATMENT. 

its  entire  contents — tlie  decidua  vera,  the  de- 
cidiia  reflexa,  tlie  amnion,  the  chorion,  and  the 
foetus.  Should  death  ensue  (which  is  not  at 
all  likely  under  ordinary  circumstances),  the 
internal  surface  of  the  uterus  would  be  found 
on  examination  to  look  very  much  like  raw 
flesh,  and  no  membranes  or  anything  else  would 
be  discovered  in  its  cavity.  If  you  will  split 
open  such  a  foetal  shell,  which  is  only  met 
with  in  the  very  early  stages  of  pregnancy  and 
is  often  incorrectly  called  a  "mole,"  you  will 
find  that  it  has  very  thick  walls  and  that  in 
its  central  cavity  there  is  a  small  amount  of 
liquor  amnii  and  a  very  small  foetus. 

In  the  second  place,  the  foetus  may  be  ex- 
pelled with  the  amnion  and  chorion,  while  the 
decidua  vera  is  left  in  the  uterus.  Wheth- 
er the  decidua  reflexa  is  expelled  with  the 
foetus  or  not  we  can  not  say,  though  this  is 
probably  the  case.  In  any  event,  however, 
this  is  of  very  little  consequence,  as  the  mem- 
brane is  very  thin  and  of  no  importance.  The 
important  point  in  this  class  of  cases  is  that 


ABORTION  AND  ITS  TREATMENT.  H 

the  lining  membrane  of  the  uterus  is  not 
ripped  away,  as  in  the  preceding.  This  mem- 
brane will  come  away  later  in  the  lochial  dis- 
charge. 

Thirdly,  the  foetus  alone  may  be  expelled. 
The  liquor  amnii  follows  the  fcetus,  which  (the 
delicate  umbilical  cord  being  severed)  makes 
its  way  through  the  amnion  and  chorion,  which 
remain  in  situ  in  the  uterus.  This  is  a  compli- 
cated case.  Very  often  the  physician  is  not 
consulted  until  three  or  four  days  after  the 
expulsion  of  the  foetus,  and  he  is  then  informed 
of  the  event  and  told  that  everything  is  satisfac- 
tory. He  probably  finds  the  patient  perfectly 
comfortable,  with  a  pulse  of  80  and  a  tempera- 
ture of  98|°,  and  she  and  her  friends  are  likely 
to  strenuously  object  to  any  interference  on  his 
part.  Under  these  circumstances  what  is  he  to 
do?  It  is  certainly  a  very  trying  position  ;  but 
if  he  does  not  insist  on  emptying  the  uterus  of 
the  contents  still  remaining  in  it,  the  chances 
are  that  he  may  again  be  summoned,  to  find 
that  the  woman  has  had  a  violent  chill  and  is 


12  ABORTION  AND  ITS  TREATMENT. 

now  in  a  high  fever,  with  all  the  signs  of  putrid 
intoxication  or  septicaemia. 

Fourthly  and  lastly,  when  utero-gestation  is 
a  little  further  advanced,  the  fcBtus  and  mem- 
branes may  be  expelled  and  the  placenta  left  be- 
hind. In  such  a  case  the  practitioner  is  apt  to 
console  himself  with  the  idea  that  everything 
has  come  away,  and  that  consequently  there  will 
be  no  further  trouble.  A  retained  placenta  is 
sometimes  difficult  of  removal,  and  you  may 
perhaps  give  yourself  the  benefit  of  the  doubt 
as  to  whether  there  is  anything  more  in  the 
uterus,  and  run  the  chances  of  escaping  evil, 
even  if  the  placenta  does  remain.  Unfortunate- 
ly, in  a  large  proportion  of  cases  the  most  seri- 
ous results  will  follow  if  the  placenta  is  allowed 
to  remain.  A  day  or  two  ago  I  consulted  a  cer- 
tain author  in  regard  to  the  prognosis  of  abor- 
tion, and  I  found  that  he  pictured  it  in  a  very 
rose-colored  way,  stating  that  there  was  but 
little  danger  of  a  fatal  issue,  and  that  the  mor- 
tality was  very  small.  The  facts  of  the  case  I 
believe    to    be    directly  the    opposite   of    this. 


ABORTION  AND  ITS  TREATMENT.  13 

There  can  be  no  question  whatever  that  a  large 
number  of  deaths  occur  which  are  directly  or 
indirectly  due  to  abortion,  but  which  are  set 
down  to  other  causes.  The  principal  lesson 
which  I  would  have  you  learn  to-day  is,  then, 
that  abortion  does  not  always  occur  in  the 
same  way,  and  that  the  physician  must  be  fully 
prepared  to  treat  each  case  according  to  its 
character  and  the  special  cii'cumstances  attend- 
ing it. 


LECTURE  II. 

The  causes  of  abortion — Maternal  causes — Poisons  in  the  blood- 
Nervous  disorders — Reflex  influences — Drugs — Foetal  causes 
— Compression  of  the  umbilical  cord — Syphilis — Rupture  of 
umbilical  vein — Injury  to  fcEtus  from  external  causes — 
Uterine  causes — Retroflexion  and  other  displacements — Fi- 
broids and  other  neoplasms — Laceration  of  the  cervix — 
Habitual  abortion — The  modus  operandi  of  the  causes  of 
abortion — Physiological  abortion  and  the  folly  of  interfer- 
ing with  it — The  use  of  ergot 

In  the  last  lecture,  you  will  remember  that 
I  gave  you  the  technical  definition  of  abortion. 
I  now  wish  to  ask,  and  answer  the  question  of 
its  meaning  from  a  different  standpoint — viz., 
from  that  of  its  natural  history.  From  this 
standpoint  what  is  the  definition  of  abortion? 
You  must  understand  that  an  abortion  may 
take  place  at  any  time  between  the  moment  of 
fixation  of  the  ovum  and  the  end  of  the  fourth 
month,  and  that  anything  whatever  which  causes 
the  uterine  body  to  contract  and  to  overcome 


ABORTION  AND  ITS  TREATMENT.  15 

the  spMncteric  action  of  the  cervix  uteri,  and 
thus  causes  the  emptying  of  the  contents  of 
the  uterine  cavity,  constitutes  this  process. 

Let  us  consider  now  what  the  causes  of 
abortion  are.  And  here  let  me  say  that  I  give 
you  these  causes  not  for  the  examination-room, 
but  for  the  bedside.  I  do  not  propose  by  any 
means  to  enumerate  all  the  causes.  To  do  so 
would  probably  take  up  our  entire  hour  ;  and  I 
have  always  held  that  the  didactic  lecture  ought 
never  to  take  the  place  of  the  text-book  for  the 
student.  What  you  ought  to  learn  from  lect- 
ures like  these  is  the  method  of  studying  a  sub- 
ject. All  the  minute  details  of  that  subject 
you  can  derive  from  private  reading,  for  all 
the  minutiae  in  any  department  of  medical  sci- 
ence are  elaborately  set  forth  in  the  systematic 
works  at  your  disposal. 

!N'ow,  suppose  that  a  woman  applies  to  you 
for  advice  who  tells  you  that  she  has  been  mar- 
ried eight  or  ten  years,  and  in  that  time  has  had 
a  dozen  abortions,  and  that  these  abortions  have 
always   occurred   about   the   end  of  the   third 

2 


16  ABORTION  AND  ITS  TREATMENT. 

month..  Or,  suppose  that  you  are  consulted  by  a 
woman  who  tells  you  that  she  has  been  married 
twenty  years,  that  nineteen  years  ago  she  gave 
birth,  after  a  perfectly  natural  labor,  to  a  well- 
developed  and  healthy  child,  and  that  since 
then  she  has  never  borne  a  child,  but  has  had  a 
considerable  number  of  abortions — always  at  the 
third  or  fourth  month.  The  problem  that  is 
presented  to  you  is  to  find  out  what  has  been 
the  cause  of  the  habitual  abortions  in  these 
cases ;  and  what  I  want  to  do  now  is  to  tell  you, 
as  far  as  I  am  able,  how  to  look  for  the  cause  of 
the  trouble  in  such  instances.  It  must  be  borne 
in  mind,  however,  that  a  considerable  number 
of  cases  are  met  with  in  practice  in  which,  not- 
withstanding the  fact  that  the  cause  of  the  abor- 
tions can  be  determined  with  positiveness,  it  is 
utterly  beyond  the  power  of  the  physician  to 
prevent  their  occurrence  ;  and,  furthermore,  that 
in  many  instances  no  assignable  cause  for  the 
abortions  can  be  discovered.  But  if  the  points 
to  which  I  am  about  to  direct  your  attention  are 
fully  impressed  upon  your  minds,  I  can  assure 


ABORTION  AND  ITS  TREATMENT.  17 

yon  that,  as  you  gain  experience,  the  number 
of  this  latter  class  of  cases  which  you  meet  with 
will  grow  steadily  smaller. 

AU  the  causes  of  abortion  can  be  divided  into 
three  classes : 

I.  Systemic,  or  those  due  to  a  general  ma- 
ternal condition. 

n.  Foetal. 

III.  Uterine. 

These  three  classes  of  causes,  as  a  rule,  are 
entirely  independent  of  each  other. 

Let  us  suppose  that,  in  the  case  of  a  woman 
who  has  had  a  number  of  abortions,  the  foetus 
and  its  envelopes  have  been  carefully  examined 
in  every  instance,  and  have  been  found  perfectly 
normal.  It  is  evident  that  disease  of  the  foetus 
has  had  nothing  to  do  with  the  causation  of 
the  accident,  and  that  there  must  be  something 
wrong  about  either  the  uterus  or  the  general 
system  of  the  mother.  As  a  rule,  however,  you 
will  not  be  able  to  secure  definite  information 
in  regard  to  the  condition  of  the  foetus  in  the 
different  abortions  without  a  long  and  careful 


18  ABORTION  AND  ITS  TREATMENT. 

investigation,  as  it  is  likely  to  be  the  case  that 
the  woman  has  been  attended  by  several  differ- 
ent physicians  at  these  times.  Hence  it  will  be 
best  first  to  make  a  thorough  examination  of 
the  general  system  of  the  patient,  and  then, 
if  you  find  nothing  about  that  to  account  for 
the  trouble,  communicate  with  any  of  the  phy- 
sicians who  have  attended  her  in  her  abortions 
who  can  be  reached,  and  learn,  if  possible, 
whether  in  any  instance  a  microscopic  exami- 
nation was  made  of  the  product  of  conception, 
and,  if  so,  whether  evidences  of  syphilis,  or 
other  disease  likely  to  bring  about  foetal  death, 
were  found  to  be  present. 

I  will  now  proceed  to  give  you  more  in 
detail  the  causes  which  come  under  each  of 
these  three  heads.  Among  the  systemic  causes, 
a  number  are  connected  with  the  nervous  sys- 
tem and  a  number  with  the  blood ;  and  I  will 
speak  first  of  the  latter.  It  is  well  known  that 
carbonic-oxide  gas  has  a  more  certain  effect  in 
exciting  uterine  contractions  than  ergot  itself. 
It  is  related  that  some  years  ago  when  Mar- 


ABORTION  AND  ITS  TREATMENT.  19 

shal  Pelissier,  at  the  head  of  a  French  army, 
was  waging  a  war  of  conquest  in  a  certain  dis- 
trict of  Algiers,  he  drove  an  Arab  tribe  into  a 
large  cave,  where  they  had  secreted  their  valu- 
ables, and  kept  them  imprisoned  there  for  some 
days.  When  the  people  were  finally  released, 
it  was  found  that  quite  a  large  number  of  the 
pregnant  women  of  the  party  had  aborted,  this 
result  being  unquestionably  due  to  the  poison- 
ing of  their  blood  by  the  carbonic-oxide  gas 
which  had  been  generated  from  the  crowding 
together  within  confined  quarters  of  so  many 
human  beings.  It  is  a  curious  fact,  also,  that 
this  poison  sometimes  has  the  effect  of  causing 
the  post-mortem  delivery  of  pregnant  women, 
and  I  myself  have  had  the  opportunity  of  ob- 
serving two  such  instances,  the  mothers  in  both 
of  them  being  nearly  at  full  term.  In  such 
instances,  which  never  occur  until  some  hours 
after  death,  the  carbonic- oxide  gas  which  prO' 
duces  the  uterine  contractions  is  given  off  from 
the  decaying  tissues. 

Among  other  poisons  in  the  blood  which  are 


20  ABORTION  AND  ITS  TREATMENT. 

capable  of  causing  abortion  are  those  which  cre- 
ate the  exanthematous  eruptions  of  small-pox, 
scarlatina,  measles,  etc.  ;  and  you  will  occasion- 
ally find  that  unusually  severe  malarial  poison- 
ing will  give  rise  to  it.  A  chill  is  nothing  but 
a  slight  convulsion,  and  in  very  malarious  dis- 
tricts the  chill  of  the  adult  is  often  replaced  by 
the  convulsion  in  children,  this  sometimes  being 
so  severe  as  to  destroy  life.  This  malarial  poi- 
soning, I  am  convinced,  is  the  cause  of  some 
of  the  cases  of  habitual  abortion  which  are  met 
with. 

Next  we  will  consider  some  of  the  nervous 
causes.  Some  women  of  highly  nervous  organi- 
zation are  liable  to  have  abortion  brought  on  by 
the  most  trivial  causes.  Indeed,  a  mere  odor 
has  been  sometimes  declared  to  produce  this  re- 
sult. The  nerves  are  more  answerable  for  abor- 
tions than  the  blood  ;  and  prominent  among  the 
nervous  disorders  which  are  apt  to  give  rise  to 
the  accident  may  be  mentioned  chorea.  Yet, 
notwithstanding  this  tendency  in  general,  I  have 
at  times  met  with  patients  in  whom  the  disease 


ABORTION  AND  ITS  TREATMENT.  21 

did  not  cause  abortion,  but  had  such  a  pro- 
found effect  upon  the  system  otherwise  that  it 
was  found  necessary  to  produce  abortion  arti- 
ficially in  order  to  save  their  lives.  Tetanus  is 
even  more  liable  than  chorea  to  cause  abortion. 
Then,  again,  the  reflex  influences  may  cause  it ; 
and  one  of  the  most  common  of  these  is  sudden 
fright,  I  once  met  with  the  case  of  a  lady  in 
perfect  health  who,  while  on  her  way  to  this 
city  on  a  railway  train  with  her  husband,  fell 
asleep  and  was  awakened  in  sudden  terror  by 
the  entrance  of  the  train  into  a  tunnel.  In- 
stantly she  felt  a  violent  uterine  pain,  and  dur- 
ing the  following  night  she  gave  birth  to  a 
foetus.  Under  the  placenta  I  found  a  clot  of 
blood  as  large  as  a  pigeon' s  egg,  which  was  un- 
questionably the  immediate  cause  of  the  abor- 
tion. The  sudden  fright  acted  primarily  on  the 
nervous  centres,  and  the  result  was  a  severe 
spasm  of  the  uterus  which  caused  placental  apo- 
plexy. In  consequence,  the  clot  mentioned  was 
formed,  and  the  irritation  of  this  clot,  acting  as 
a  foreign  body,   gave  rise  to  the  contractions 


22  ABORTION  AND  ITS  TREATMENT. 

which  in  a  few  hours  resulted  in  the  emptying 
of  the  uterus. 

Again,  there  are,  as  you  know,  certain  drugs 
— such  as  ergot,  cotton-root,  viscum  album,  and 
others  which  I  need  not  enumerate — which  have 
a  specific  action  on  the  uterus  and  sometimes 
produce  abortion.  It  is  only  necessary  to  state 
that  ergot  is  the  typical  agent  of  this  class. 

When  in  any  case  of  habitual  abortion  you 
have  ^  excluded  those  causes  originating  in  the 
system  of  the  mother,  you  will  have  to  direct 
your  attention  to  the  foetus.  As  to  the  foetal 
causes  of  abortion,  it  may  be  stated  as  a  gen- 
eral proposition  that  anything  which  will  kill 
the  foetus  will  produce  an  abortion.  There  are 
only  two  things  which  can  happen  to  the  dead 
foetus  if  it  is  not  cast  off.  One  of  these  is 
atheromatous  or  fatty  degeneration,  resulting  in 
the  so-called  "mole,"  or  in  that  very  rare  and 
curious  calcification  known  as  uterine  stone. 
But  in  the  great  majority  of  cases  the  decaying 
foetus,  acting  on  the  nerves  of  the  uterus,  pro- 
duces contraction  and  expulsion. 


ABORTION  AND  ITS  TREATMENT.  23 

During  the  later  months  of  pregnancy  the 
membranes  and  other  appendages  of  the  foetus 
are  constantly  liable  to  get  out  of  order,  and, 
by  reason  of  sudden  movements  of  the  foetus, 
the  umbilical  cord  is  especially  apt  to  become 
twisted  or  tied  in  a  knot,  occlusion  of  its  vessels 
sometimes  resulting  in  the  death  of  the  foetus. 
I  once  knew  of  a  woman  who  in  the  ninth  month 
of  pregnancy  felt  the  child  bound  in  her  uterus. 
She  very  soon  became  ill,  and  suffered  greatly 
until  she  was  delivered  at  full  term.  It  was 
then  found  that  there  were  two  children  in 
utero,  one  of  which  was  in  a  perfectly  healthy 
condition,  though  it  was  still-born,  while  the 
body  of  the  other  was  so  swollen  and  emphy- 
sematous that  it  had  to  be  removed  piecemeal. 
This  putrefaction  had  come  on  during  the  two 
weeks  that  the  foetus  (which  had  no  doubt  been 
killed  by  the  knotting  of  the  cord  resulting  from 
its  violent  movement)  had  remained  dead  in  the 
uterus.  The  mother  unfortunately  died  of  sep- 
ticaemia after  the  labor.  Of  course,  the  umbili- 
cal cord  is  not  liable  to  get  into  a  knot  in  the 


24  ABORTION  AND  ITS  TREATMENT. 

earlier  months  of  pregnancy ;  but  injury  to  it 
may  occur  as  early  as  tlie  fourth  month. 

Syphilis  is  one  of  the  two  most  frequent 
causes  of  habitual  abortion.  It  may  be  de- 
rived from  the  father  or  mother,  or  from  both 
parents,  and  it  affects  not  only  the  child,  but 
the  membranes,  causing  fatty  degeneration  of 
the  placenta,  and  thus  interfering  with  the 
aeration  of  the  blood  supplied  to  the  foetus. 

Finally,  I  should  mention  one  other  cause, 
and  that  is  injury  to  the  foetus  from  external 
influences.  As  an  illustration  of  this  I  will 
refer  to  the  case  of  a  lady  who,  while  walking 
across  her  bed-chamber  in  the  dark,  ran  against 
the  corner  of  a  table,  striking  her  abdomen, 
though  not  with  any  great  force.  She  thought 
nothing  more  of  this  occurrence,  but  in  two 
weeks  after  it  she  had  an  abortion,  and  an  ex- 
amination of  the  foetus,  which  was  not  quite 
four  months  old,  showed  that  it  had  been  struck 
upon  the  spine  by  the  blow  referred  to.  This 
was  unquestionably  the  cause  of  its  death  and 
the  resulting  abortion.    A  case  like  this  shows 


ABORTION  AND  ITS  TREATMENT.  25 

with  what  care  in  abortion  we   must  go  over 
the  possible  causes  of  the  accident. 

Now  for  the  uterine  causes.  The  second  of 
the  two  grand  factors  in  causing  abortion  of 
which  I  spoke  (the  first  being  syphilis)  is  retro- 
flexion of  the  uterus.  As  to  the  time  when 
abortions  usually  take  place,  it  is  a  well-estab- 
lished fact,  about  which  there  can  be  no  possi- 
ble doubt,  that  a  large  proportion  of  all  abor- 
tions occur  about  the  end  of  the  third  month. 
Hence,  if  you  have  a  patient  who  has  been 
subject  to  abortion,  you  should  by  all  means 
keep  her  strictly  quiet  at  this  particular  time. 
Why,  you  may  ask,  are  abortions  so  especially 
liable  to  come  at  this  time  ?  There  are  several 
reasons  for  this.  In  the  first  place,  this  is  the 
third  menstrual  period,  when  the  nutrition  of 
the  foetus  is  changing  its  character;  secondly, 
the  placenta  is  now  rapidly  developing ;  and, 
thirdly,  the  uterus  is  beginning  to  rise  out 
of  the  pelvis.  It  is  the  time,  moreover,  when 
syphilis,  if  present,  affects  the  placenta,  and 
when  retroflexion  is  most  apt  to  be  attended 


X 


26  ABORTION  AND  ITS  TREATMENT. 

by  the  conditions  instrumental  in  producing 
abortion.  I  wish  it  to  be  clearly  understood 
that  I  am  speaking  now  of  habitual  abor- 
tion. 

It  is  impossible  for  me  to  enumerate  all  the 
causes  of  abortion.  I  therefore  ask  you  to 
think  for  yourselves,  guided  by  such  hints  as 
I  am  able  to  give  you  from  my  own  experience. 
If  you  will  stop  to  consider,  you  will  readily 
see  that  uterine  fibroids,  whether  submucous  or 
interstitial,  and  other  neoplasms,  must  necessa- 
rily be  a  frequent  cause  of  habitual  abortion. 

Tl;iere  are  still  other  uterine  causes  which  I 
am  unwilling  to  pass  over  without  mention. 
The  cervix  uteri,  as  you  know,  is  not  obliter- 
ated until  a  late  period  in  utero-gestation.  It 
offers  a  suitable  place  for  the  foetal  mass  to 
rest  upon,  and  also  serves  to  protect  the  latter 
from  disturbing  influences  from  below.  In  cer- 
tain cases,  however,  owing  to  a  laceration  of 
the  external  os  in  a  previous  labor,  the  cer- 
vix is  completely  obliterated  from  below,  and 
laceration   of   it   must    therefore    be    borne    in 


ABORTION  AND  ITS  TREATMENT.  27 

mind  as  one  of  the  causes  of  repeated  abor- 
tions. But  we  are  liable  to  make  a  great  many 
mistakes  if  we  expect  that  in  every  case  of 
habitual  abortion  in  which  such  a  laceration 
exists  we  can  put  an  end  to  this  trouble  by 
sewing  up  the  everted  lips  of  the  torn  os.  In 
many  instances  this  operation  will  undoubtedly 
put  an  end  to  the  habit  of  abortion,  but  in 
others  you  will  find,  after  you  have  performed 
it,  that  the  latter  has  been  due  to  some  other 
cause.  Many  women  will  go  on  bearing  chil- 
dren to  full  term,  notwithstanding  the  most  ex- 
tensive lacerations  of  the  os ;  and  others,  with 
such  lacerations,  will  continually  have  abor- 
tions. The  difference  in  these  two  classes  of 
cases  lies  in  the  different  nervous  organizations 
of  the  women  themselves. 

Now,  a  word  further  in  regard  to  uterine  dis- 
placements. In  all  the  various  forms  of  dis- 
placement, such  as  prolapse,  anteflexion,  retro- 
version, and  retroflexion,  abortions  are  liable  to 
be  met  with,  but  in  all  except  the  last  named 
they  are  comparatively   rare.      In  retroflexion 


28  ABORTION  AND  ITS  TREATMENT. 

they  are  exceedingly  common,  and,  as  I  have 
already  pointed  out,  this  condition  and  syphi- 
lis constitute  the  two  grand  factors  in  the  pro- 
duction of  habitual  abortion.  The  special  rea- 
son why  retroflexion  so  often  leads  to  abortion 
is  the  marked  vascular  engorgement  which  is 
incident  to  this  form  of  displacement. 

As  to  the  method  in  which  the  various 
causes  act,  in  the  case  of  the  accumulation  of 
carbonic-oxide  gas  in  the  blood  the  action  is 
directly  upon  the  uterus  itself,  as  shown  by 
the  fact  that  it  is  capable  of  causing  post-mor- 
tem delivery  ;  but,  as  a  rule,  the  modus  ope- 
randi of  these  causes  is  through  the  nervous 
system. 

Let  us  suppose  that  the  command  goes  forth 
from  the  nervous  centres  that  the  fundus  uteri 
shall  contract.  In  the  normal  condition  the 
sphincteric  action  of  the  cervix  resists  the  press- 
ure of  the  uterine  body  from  above  ;  but  as  the 
latter,  under  the  influence  of  the  nervous  sys- 
tem, goes  on  contracting,  this  resistance  will 
gradually  be  overcome.     At  first  the  woman  ex- 


ABORTION  AND  ITS  TREATMENT.  29 

periences  bearing-down  pains  (as  they  have  been 
very  properly  designated)  at  long  intervals,  but 
later  they  occur  at  short  ones.  The  os,  acted 
upon  by  two  forces,  begins  to  dilate.  The  first 
of  these  forces  consists  of  the  plug-like  action 
of  the  foetal  ball,  and  the  second  is  the  influ- 
ence of  the  nervous  system.  In  a  little  while 
the  OS  internum  opens,  and  then  the  whole 
canal  does  so,  while  the  membranes  begin 
gradually  to  detach  themselves.  If  the  pla- 
centa is  formed,  that  also  becomes  slightly 
detached,  and  the  woman  begins  to  bleed — 
often  to  an  alarming  and  sometimes  to  a  fatal 
extent. 

The  uterus  goes  on  forcing  down  its  con- 
tents, and  at  length  a  plug  gets  fully  into  the 
cervical  canal,  this  plug  very  rarely  comprising 
the  whole  foetal  shell,  or  consisting,  as  is  the 
very  general  rule,  of  the  membranes  enveloping 
the  foetus,  without  the  decidua  iiera.  Here  let 
me  say  a  word  in  regard  to  the  old  adage,  "med- 
dlesome midwifery  is  bad."  There  can  be  no 
question  that  this  quotation  is  sometimes  used 


30  ABORTION  AND  ITS  TREATMENT. 

as  a  cloak  for  ignorance ;  but  at  the  same  time 
it  is  true  that  meddlesome  midwifery,  properly 
so  called,  is  Just  as  bad  now  as  it  was  in  the 
days  of  Hippocrates.  The  process  of  expulsion 
Just  described  constitutes  the  natural  history  of 
abortion  ;  therefore  interfere  with  it  as  little 
as  possible. 

This  is  a  maxim  which  it  is  very  difficult 
for  the  young  practitioner  to  respect !  There  is 
a  great  temptation  to  remove  the  foetus  ;  but 
if  you  do  this  the  chances  are  that  the  mem- 
branes will  be  left,  and  if  this  be  the  case  they 
are  likely  to  cause  you  many  a  sleepless  night 
before  all  the  consequences  of  your  ill-timed 
interference  are  over.  But  you  may  perhaps 
say,  "  Why,  the  woman  is  bleeding  to  a  dan- 
gerous degree."  If  the  haemorrhage  is  really 
alarming,  it  is  certainly  your  duty  to  control 
that  at  all  events ;  but  as  to  the  pain  that  the 
woman  is  suffering,  it  is  better  that  she  should 
have  this  pain  than  that  the  uterine  contrac- 
tions should  be  interfered  with  by  the  use  of 
opium  or  other  drugs.    Opium  is  often  a  price- 


ABORTION  AND  ITS  TREATMENT.  31 

less  boon  in  parturition,  but  it  must  always  be 
used  with  the  greatest  discrimination. 

After  the  cervix  is  sufficiently  dilated  to  ad- 
mit the  greatest  diameter  of  the  foetal  shell,  the 
entire  contents  of  the  uterine  cavity  can  readily 
come  away,  and  there  is  likely  to  be  no  further 
trouble.  Everything  has  gone  well  because  it 
has  been  a  physiological  process.  It  is  of  the 
greatest  importance  that  the  labor-pains  should 
duly  perform  their  function.  Anything  which 
breaks  the  bag  of  water  and  lets  out  the  liquor 
amnii  is  a  misfortune,  and- anything  which  sepa- 
rates the  foetus  from  the  membranes  is  a  still 
greater  misfortune.  During  an  abortion  the  at- 
titude of  the  physician,  beyond  the  control  of 
haemorrhage,  should  be  an  expectant  one.  He 
should  let  the  process  take  its  natural  course 
and  only  offer  his  assistance,  as  he  would  apply 
the  forceps  in  labor  at  full  term,  when  Nature 
is  unable  to  complete  the  delivery. 

Some  of  you  would  perhaps  like  to  ask  me 
whether  I  would  not  use  ergot  under  these  cir- 
cumstances.    Ergot  is  indeed  excellent  in  its 

3 


32  ABORTION  AND  ITS  TREATMENT. 

place,  but  it  often  does  a  great  deal  of  harm. 
Both  in  labor  and  in  abortion  it  should  be 
withheld  until  there  is  no  decided  obstruction 
to  delivery ;  but,  when  this  is  the  case,  one  full 
dose  may  often  be  given  in  the  later  stages 
with  the  most  satisfactory  results.  If  it  is 
given  in  abortion,  this  should  be  only  when 
the.  cervix  has  become  sufficiently  dilated  to 
admit  the  maximum  part  of  the  foetal  shell. 


LECTURE  III. 

The  habit  of  abortion — Exceptions  to  the  ordinary  rules  gov- 
erning abortion — Criminal  abortion — Retention  of  the  prod- 
uct of  conception  under  extraordinary  circumstances — The 
absurdity  of  so-called  maternal  impressions  —  Great  fre- 
quency of  abortion — Prognosis  in  abortion — As  to  life — As 
to  health — Elements  of  danger  in  abortion — Hjemorrhage — 
Putrid  intoxication — Septicsemia  and  peritonitis — Suppura- 
tive arthritis — Cellulitis  and  abscess — Embolism — Tetanus — 
Uterine  hydatids — Melancholia. 

One  word  further  in  regard  to  syphilis, 
which,  as  I  said  before,  constitutes,  with  the 
exception  of  retroflexion  of  the  uterus,  the  most 
important  factor  in  the  production  of  habitual 
abortion.  In  order  to  discover  its  existence  you 
should  make  a  careful  examination  of  the  prod- 
uct of  conception  after  it  is  cast  off,  as  well  as 
of  both  parents.  In  many  instances  the  evi- 
dences of  the  disease  are  sufficiently  plain  to 
the  naked  eye  either  in  the  foetus  itself  or  in 
the  secundines.      In   others  it  is  necessary  to 


34  ABORTION  AND  ITS  TREATMENT. 

make  a  microscopical  examination  to  ascertain 
the  existence  of  the  disease. 

Before  I  leave  entirely  the  subject  of  causa- 
tion, I  wish  to  speak  for  a  moment  of  the  TiaMt 
oi  abortion.  You  will  understand,  I  trust,  that 
this  unscientific  designation  is  only  applied  to 
a  certain  class  of  cases  for  which  we  have  no 
better  term.  In  every  case  of  abortion  there  is, 
of  course,  a  definite  cause ;  but  sometimes  this 
cause  is  so  obscure  or  so  slight  as  to  entirely 
escape  notice.  There  are  many  delicate  refined 
women  of  nervous  temperament  in  whom  the 
mere  hearing  of  something  unpleasant  or  repul- 
sive will  excite  nausea  and  vomiting,  because 
their  nervous  systems  are  thoroughly  hyperses- 
thetic,  and  in  this  class  of  cases  the  slightest 
cause  is  often  sufficient  to  induce  an  abortion. 
Such  women  are  so  constituted  as  to  their  nerv- 
ous systems  that  it  takes  very  little  to  make 
the  uterus  bear  down  on  its  contents  and  expel 
them.  It  is  very  difficult  for  a  woman  of  this 
kind,  even  under  the  most  favorable  circum- 
stances, to  go  to  full  term  without  encounter- 


ABORTION  AlTD  ITS  TREATMENT.  35 

ing  some  occurrence  that  will  give  rise  to  a 
premature  expulsion  of  the  product  of  concep- 
tion. This,  then,  is  what  I  refer  to  as  the 
habit  of  abortion,  and  the  expression  is  re- 
sorted to  only  after  we  are  driven  to  the  wall, 
as  it  were ;  every  other  cause  for  the  accident 
having  been  carefully  excluded. 

I  now  ask  you  to  consider  some  exceptions 
to  the  ordinary  rules  governing  abortion.  There 
are  some  women  who  are  just  the  opposite  of 
those  in  whom  we  find  the  extreme  facility  of 
abortion  which  has  just  been  referred  to ;  they 
are  so  hardy  that  it  is  exceedingly  difficult  for 
them  to  get  rid  of  the  contents  of  the  uterus 
before  the  normal  termination  of  pregnancy. 
Incidentally  I  may  here  remark  that  the  prac- 
tice of  criminal  abortion  is  common  in  this 
country,  and  women  often  perform  it  on  them- 
selves. They  often  learn  how  to  introduce  the 
sound  into  the  uterus  themselves,  and,  having 
done  so,  they  move  it  about  from  side  to  side 
until  they  excite  the  organ  to  contraction ;  and 
when  the  process  of  abortion  begins  they  take 


36  ABORTION  AND  ITS  TREATMENT. 

drugs,  of  which  they  have  read  in  books,  to 
facilitate  the  expulsion  of  the  troublesome  prod- 
uct of  conception.  With  many  women,  you 
must  understand,  abortion  is  not  regarded  as  a 
great  crime,  and  they  are,  unfortunately,  prone 
to  condone  it. 

In  this  connection,*  let  me  give  you  a  re- 
markable case  which  occurred  in  my  own  expe- 
rience. On  one  occasion,  a  few  years  ago,  I  was 
sitting  at  breakfast,  when  the  servant  announced 
that  there  was  a  gentleman  down-stairs  asking 
to  see  me  who  seemed  to  be  crazy.  I  according- 
ly went  down,  and  found  a  fine-looking  man 
about  thirty-five  years  of  age  who  was  walking 
the  floor  and  appeared  to  be  in  a  perfect  agony 
of  anxiety  and  excitement.  He  told  me  that  he 
was  a  physician  from  a  western  town,  and  that 
he  had  come  on  with  his  wife  who  had  injured 
herself  in  an  attempt  to  produce  an  abortion. 
He  stated  that  his  wife,  believing  herself  to  be 
pregnant,  had  become  so  alarmed,  from  the  fact 

*  This  case,  at  the  time  of  its  occurrence,  was  published  in 
detail  in  the  American  Journal  of  the  Medical  Sciences. — P.  B.  P. 


ABORTION  AND  ITS  TREATMENT.  37 

that  at  her  last  confinement  she  had  suffered 
severely  from  puerperal  fever,  and  that  she  had 
insisted  on  getting  rid  of  the  product  of  concep- 
tion by  artificial  means  herself.  Accordingly, 
wishing  to  humor  her,  he  had  procured  and  pre- 
pared for  her  an  iron  umbrella-rib,  telling  her 
that  if  she  would  introduce  it  into  the  uterus 
her  purpose  would  be  accomplished.  In  his 
absence  she  had  attempted  this  procedure,  and 
found  that  the  rib,  having  once  been  pushed 
in,  kept  going  on  and  on,  until  at  last  it  was 
suddenly  grasped  by  something  and  pulled  up 
entirely  out  of  her  reach,  disappearing  within 
the  uterus.  In  answer  to  my  inquiry  how  long 
his  wife  had  been  pregnant,  he  replied  "two 
months." 

Though  this  story  seemed  utterly  improbable, 
I  at  once  went  to  see  his  wife  at  her  hotel,  and 
found  a  very  handsome  woman  lying  in  bed 
apparently  in  a  perfectly  healthy  condition. 
Her  pulse  and  temperature  were  normal,  and 
she  stated  that  she  suffered  no  pain  whatever, 
and  that  the  only  thing  of  which  she  complained 


3S  ABORTION  AND   ITS  TREATMENT. 

was  a  slight  cougli.  Under  tlie  circumstances 
I  thonght  it  best  to  make  an  examination  of 
her  chest,  and  asked  her  to  sit  np  in  bed  for 
this  purpose.  As  soon  as  she  did  this  she 
gave  a  sudden  gasp,  as  though  she  were  in 
great  agony,  and  she  suffered  so  greatly  from 
difficulty  of  breathing  that  it  was  five  minutes 
before  I  could  go  on  with  the  examination. 

I  then  believed  that  the  history  told  by  her 
husband  was  true,  and,  fearing  that  the  most 
serious  consequences  might  ensue,  I  determined 
to  perform  laparotomy  at  once.  Every  prepara- 
tion was  accordingly  made  for  the  operation, 
but  just  as  the  ether  cone  w^as  about  to  be  ap- 
plied to  her  face  an  uncle  of  hers,  who  was 
present,  remarked  to  me  that  if  I  proceeded 
it  must  be  on  my  own  responsibility,  and 
that  if  anything  untoward  happened  he  would 
invoke  the  law  to  punish  me  for  my  temerity. 
This  announcement  somewhat  startled  me,  and, 
as  I  had  undertaken  the  case  merely  to  help  a 
fellow-practitioner  who  was  in  sore  distress,  I 
asked  the  patient  if  she  would  take  the  risk 


ABORTION  AND  ITS  TREATMENT.  39 

of  the  operation,  and  she  said  "no."  I  then 
asked  her  if  it  was  really  true  that  she  had 
used  the  umbrella-rib  and  it  had  disappeared, 
as  stated,  and  she  replied  that  "she  didn't 
know."  In  such  a  state  of  affairs  I  felt  that 
it  would  be  utterly  unjustifiable  for  me  to  go 
on  with  the  laparotomy,  and  I  accordingly  or- 
dered that  the  instruments  which  had  been 
made  ready  should  be  put  up.  In  a  week  after 
this  the  woman  died. 

The  husband  utterly  refused  to  have  an 
autopsy  made  ;  but,  as  I  was  unwilling  to  give  a 
certificate  of  death  without  learning  something 
more  about  this  obscure  case,  I  insisted  on 
placing  it  in  the  coroner's  hands,  and  was  thus 
enabled  to  obtain  a  post-mortem  examination. 
The  result  of  the  examination  was  as  follows  :  I 
found  a  non-pregnant  uterus  of  normal  size,  and 
just  to  the  right  of  the  cervix  uteri  there  was 
a  puncture  of  the  vaginal  wall,  evidently  made 
by  the  umbrella-rib  mentioned.  Through  this 
orifice  the  rib  had  gone,  and  as  it  passed  up- 
ward   through    the    abdominal    cavity    it    had 


40  ABORTION  AND  ITS  TREATMENT. 

scraped  the  surface  of  the  liver.  After  trans- 
fixing  the  diaphragm,  it  penetrated  the  right 
lung  to  the  extent  of  two  or  three  inches,  and 
in  this  position  it  was  found  at  the  autopsy. 
It  was  no  doubt  a  spasm  of  the  diaphragm,  re- 
sulting from  the  irritation  of  the  rib  piercing 
it,  which  had  caused  the  sudden  snatching  up- 
•ward  of  the  latter,  as  described  by  the  hus- 
band in  his  narrative. 

The  rib  was  thirteen  inches  in  length,  with 
its  point  somewhat  sharpened,  and  surrounding 
its  upper  extremity,  in  the  lung  tissue,  there 
was  an  abscess,  which  had  not  as  yet  discharged, 
but  from  which  septic  inflaences  had  emanated. 
I  mention  this  case  not  only  on  account  of 
its  peculiar  interest,  but  to  show  you  to  what 
lengths  women  will  go  under  these  circum- 
stances. In  this  instance  it  was  the  dread  of 
another  attack  of  puerperal  fever  which  ren- 
dered the  patient  morbidly  anxious  about  the 
matter. 

But  to  return  to  those  exceptional  cases  in 
which  the  product  of  conception  is  retained  un- 


ABORTION  AND  ITS  TREATMENT.  41 

der  circumstances  which,  in  the  vast  majority  of 
instances,  would  at  once  result  in  its  expulsion. 
In  Paris  pregnant  young  women  who  have  at- 
tempted suicide  by  jumping  into  the  Seine,  and 
have  been  rescued,  have  been  known  to  go  on 
to  full  term  without  the  slightest  threatening  of 
abortion,  notwithstanding  the  tremendous  shock 
and  mental  strain  incident  to  such  an  adventure. 
There  is  a  case  related,  by  Mauriceau  I  think, 
in  which  a  pregnant  woman,  excited  by  an 
alarm  of  fire,  jumped  from  an  upper  window, 
and,  breaking  through  a  shed  by  the  force  of 
her  descent,  struck  upon  the  stone  flagging  be- 
low. When  she  was  picked  up  it  was  found 
that  several  of  the  bones  of  her  body  were 
broken,  but,  nevertheless,  she  passed  on  to  full 
term  as  though  nothing  had  happened. 

Some  years  ago  while  a  lady,  whom  I  knew 
very  well,  was  walking  out  one  day  in  the 
woods  with  her  husband,  a  huge  black-snake 
sprang  out  apparently  from  the  bushes  and 
coiled  itself  several  times  around  her  neck,  at 
the  same  time  spattering  her  with  blood.     Her 


42  ABORTION   AND  ITS  TREATMENT. 

young  brother  had  killed  the  snake,  and,  con- 
cealing himself  in  the  shrubbery,  had  intended 
to  throw  it  down  in  the  path  before  his  sister, 
but  missed  his  aim,  with  the  result  stated.  The 
lady,  who  was  at  the  fourth  month  of  preg- 
nancy, was  so  badly  frightened  that  she  was 
thrown  into  a  state  of  hysterical  syncope,  from 
which  she  did  not  recover  for  hours,  and  for 
several  days  suffered  from  violent  hysterical 
convulsions ;  so  that  she  seemed  almost  at  the 
point  of  death.  Yet,  notwithstanding  this  fear- 
ful shock  to  her  nervous  system,  the  uterus 
never  showed  the  slightest  tendency  to  contract, 
and  her  child  was  born  at  full  term.  Before  its 
birth  I  was  consulted  as  to  whether  I  thought 
the  infant  would  be  marked  as  a  result  of  the 
impression  made  upon  the  mind  of  the  mother 
by  this  incident,  and  I  replied  that  I  felt  abso- 
lutely sure  that  nothing  of  the  kind  was  to  be 
apprehended.  The  sequel  proved  that  I  w^as 
correct. 

I  have  just  received  a  note  from  one  of  you 
asking   my   view   as    to    maternal    impressions 


ABORTION  AND  ITS  TREATMENT.  4,3 

upon  the  foetus  in  utero.  I  believe  that  it  is 
utterly  impossible  for  a  maternal  impression 
to  be  stamped  upon  the  body  of  the  foetus. 
The  latter  is  to  all  intents  and  purposes  out- 
side of  the  mother's  influence,  and  Yirchow, 
the  great  microscopist,  has  never  been  able  to 
detect  distinct  nerve  connection  between  the 
two.  Wherever  there  has  occurred  a  case  which 
has  seemed  to  confirm  the  old  idea  of  the  child 
being  affected  in  this  way,  it  has  been,  I  think, 
simply  a  coincidence ;  and  the  argument  in  fa- 
vor of  the  agency  of  maternal  impressions  in 
producing  such  an  effect  is  one  of  post  hoc, 
not  propter  Tioc. 

What  is  the  frequency  of  abortion  ?  This  is 
something  which  we  do  not  know,  and  which, 
from  the  nature  of  the  circumstances  attending 
abortion,  we  can  never  find  out  with  positive- 
ness.  Statistics  have  fallen  into  disrepute  by 
being  made  to  apply  to  things  which  can  not 
be  definitely  ascertained.  The  premature  cast- 
ing off  of  the  product  of  conception  is  often 
kept  a  secret,  even  when  there  is  no  criminal- 


4A  ABORTION  AND  ITS   TREATMENT. 

ity  connected  with  the  occurrence.  But,  though 
I  can  not  give  you  any  figures,  I  want  to  im- 
press upon  you  the  fact  that  abortion  is  exceed- 
ingly common.  Nature  seems  to  have  ordained, 
not  only  among  plants  and  the  lower  animals, 
but  also  in  the  human  race,  that  the  amount  of 
generative  material  should  be  enormous,  and 
also  that  a  large  proportion  of  it  should  be  de- 
stroyed. 

In  the  gynaecological  clinics  which  I  have 
held  for  many  years  in  this  college  it  has 
always  been  exceptional  to  find  a  woman  coming 
before  the  class  who  could  say  that  she  had  had 
eight  or  ten  children  and  never  had  an  abor- 
tion. In  the  npper  walks  of  life  also  abortion 
is  extremely  common,  but  less  so  than  in  the 
lower. 

In  regard  to  the  prognosis  in  abortion  it  is 
impossible  to  speak  accurately,  because  reliable 
statistics  are  not  attainable,  and  we  can  not 
say,  therefore,  what  the  percentage  of  deaths 
is.  I  would  say,  in  general,  however,  that  the 
prognosis  is  good,  except  in  criminal  cases  and 


ABORTION  AND  ITS  TREATMENT.  45 

in  cases  where  antiseptic  methods  are  neglected 
in  the  treatment.  I  am  speaking  now,  you  will 
understand,  of  the  prognosis  as  to  life.  As  to 
the  matter  of  health  I  can  not  express  the  same 
opinion,  for  it  is  an  unfortunate  fact  that  vast 
numbers  of  women  are  invalided  by  abortion. 
Criminal  abortions  are  usually  performed  by 
charlatans,  in  the  roughest  and  most  unscien- 
tific manner,  and  it  is  no  wonder  that  the  results 
are  so  frequently  disastrous.  When,  however, 
abortion  is  artificially  produced  by  the  intelli- 
gent physician,  in  fulfillment  of  indications  fur- 
nished by  science,  the  prognosis  is  not  bad. 

If  a  woman  dies  during  or  after  an  abortion, 
what  is  it  that  kills  her?  In  order  to  under- 
stand this  we  must,  first  of  all,  appreciate  what 
is  taking  place.  The  foetal  shell,  consisting  of 
decidua  reflexa,  chorion,  amnion,  and  placenta 
(if  the  latter  has  been  developed),  has  got  to 
come  out.  The  decidua  vera  is  usually  torn 
away  in  places.  Let  us  inquire,  therefore,  what 
are  the  elements  of  danger,  or  the  seqiielse  of 
abortion. 


46  ABORTION  AND  ITS  TREATMENT. 

The  principal  ones  may  be  stated  as  follows : 

1.  Hsemorrhage. 

2.  Putrid  intoxication. 

3.  Septicaemia  and  peritonitis. 

4.  Suppurative  arthritis. 

5.  Cellulitis  and  abscess. 

6.  Embolism, 

7.  Air  in  the  veins. 

8.  Tetanus. 

9.  Uterine  hydatids. 

10.  Melancholia. 

The  first  five  of  these  conditions  are  common 
as  sequelae  of  abortion ;  the  last  five  are  rare 
pathological  curiosities. 

Let  us  suppose  that  you  check  the  haemor- 
rhage. Is  the  woman  perfectly  safe  ?  No.  It 
may  be  that,  even  if  the  physiological  process  is 
not  interfered  with  by  the  administration  of 
opium  or  other  sedatives,  the  uterus  will  not  be 
able  to  expel  its  contents.  In  a  short  time  pu- 
trefaction of  the  product  of  conception  ensues, 
absorption  from  it  takes  place,  and  the  patient 
suffers  from  what  is  known  as  putrid  intoxica- 


ABORTION  AND  ITS  TREATMENT.  47 

tion.  The  effect  is  the  same  as  that  which  would 
be  produced  on  any  one  by  making  an  opening 
in  the  arm  and  inserting  within  it,  so  that  it  will 
come  in  contact  with  the  tissues,  a  piece  of  tlesh„ 
As  the  latter  undergoes  putrefaction  the  whole 
system  will  become  more  or  less  infected,  as 
indicated  by  headache,  pains  in  the  back  and 
limbs,  quickened  pulse,  high  temperature,  and 
a  general  feeling  of  malaise. 

You  will  notice  that  I  put  septicaemia  and 
peritonitis  together  under  one  head.  I  do  this 
because,  in  my  opinion,  peritonitis  following 
abortion  never  occurs  as  primary  peritonitis,  un- 
less it  is  of  traumatic  origin — that  is,  unless  the 
peritonaeum  has  in  some  way  been  wounded.  In 
other  words,  the  peritonitis  which  follows  abor- 
tion is,  as  a  rule,  septic  in  character.  As  to  the 
origin  of  the  septicaemia  and  peritonitis ;  the 
finger  of  the  physician  may  convey  to  the  parts 
the  poison  giving  rise  to  the  trouble  without  any 
influence  from  the  secundines  themselves.  It  is 
now  just  nine  years  ago  since  I  had  a  very  pain- 
ful realization  of  how  very  small  an  amount  of 
4 


4:8  ABORTION  AND  ITS  TREATMENT. 

sucli  poison  may  cause  the  most  serious  results. 
Just  after  the  opening  of  my  private  hospital  I 
was  one  day  performing  an  ojjeration  for  the 
removal  of  a  sloughing  fibroid,  and  it  was  no- 
ticed by  all  present  that  the  odor  arising  from 
the  putrid  mass  was  of  the  most  disagreeable 
description.  While  I  was  washing  my  instru- 
ments after  the  completion  of  the  operation  I 
chanced  to  prick  my  little  finger  with  the  point 
of  a  tenaculum  which  had  been  used  during  the 
operation.  This  was  before  the  days  of  bichlo- 
ride in  surgery  ;  but  I  at  once  sucked  the  wound 
thoroughly,  and  not  only  washed  it  with  a  car- 
bolic-acid solution,  but  applied  some  pure  car- 
bolic acid  to  it.  This  was  at  3  p.  m.  At  7  p.  m. 
on  the  same  day  I  had  a  slight  chill,  and  by  the 
next  morning  my  finger  was  enormously  swol- 
len, while  there  rapidly  followed  enlargement 
of  the  lymphatic  glands  of  the  arm,  and  an 
abscess  formed  in  the  palm  of  the  hand. 

All  this  followed  from  the  introduction  of  a 
minute  portion  of  septic  material  into  a  part 
not  very  vascular  or  abundantly  supplied  with 


ABORTION  AND  ITS  TREATMENT.  49 

nerves.  Suppose  that  such  an  accident  should 
occur  in  connection  with  a  uterus  enormously- 
vascular  and  with  its  innervation  exalted  to  the 
highest  pitch,  as  is  the  case  during  pregnancy, 
and  you  can  imagine  what  the  result  would  be. 
Now  as  to  suppurative  arthritis  resulting 
from  abortion.  Some  twenty  years  ago  I  had  a 
lesson  taught  me  which  I  never  can  forget.  My 
friend  Dr.  Lewis  A.  Sayre,  who  was  ill,  asked 
me  to  see  for  him  a  patient  who  had  recently 
had  an  abortion,  and  on  visiting  her  I  found  the 
wrist,  elbow,  and  ankle  enlarged  and  painful 
from  what  seemed  plainly  to  me  to  be  acute 
articular  rheumatism.  About  a  week  later  I 
was  asked  by  Dr.  Sayre  to  see  the  same  patient 
with  him,  and  you  can  imagine  my  surprise 
and  chagrin  when  I  found  an  accumulation  of 
pus  in  each  of  the  joints  named.  Since  then  I 
have  always  been  very  suspicious  of  every  case 
that  seemed  like  acute  articular  rheumatism 
when  the  patient  has  recently  had  an  abortion, 
and  I  would  earnestly  caution  you  to  be  on  your 
guard  in  regard  to  such  cases,  for  the  trouble 


50  ABORTION  AND  ITS  TREATxMENT. 

is  much  more  likely  to  be  suppurative  arthritis 
than  rheumatism.  Such  arthritis  sometimes 
ends  in  death,  but,  fortunately,  the  patient  just 
mentioned  recovered.  This  case  illustrates  very 
weYL  w^hat  I  said  to  you  in  the  first  lecture  of  the 
difference  between  learning  and  being  taught. 
Here  I  had  to  learn  by  my  own  experience  what 
I  ought  to  have  been  taught  by  my  instructors. 

I  will  not  stop  to  speak  particularly  of  cellu- 
litis and  abscess,  but  will  pass  on  to  the  next 
element  of  danger.  A  certain  number  of  cases 
of  abortion  end  very  curiously.  You  are  sud- 
denly called  to  a  patient  who  has  had  an  abor- 
tion, and  find  that  she  has  all  at  once  become 
hemiplegic,  and  that  the  cause  of  the  trouble  is 
embolism.  In  my  large  experience  I  have  seen 
but  two  such  cases. 

The  entrance  of  a  small  amount  of  air  into 
the  veins  is  not  likely  to  prove  very  serious,  but 
when  air  gets  into  the  large  sinuses  which  are 
found  in  connection  with  the  pregnant  uterus, 
a  fatal  result  is  very  apt  to  occur.  I  know  of 
a  case    of   criminal    abortion,   which    occurred 


ABORTION   AND  ITS  TREATMENT.  51 

some  years  ago,  in  a  town  about  thirty  miles 
from  New  York,  in  which  the  patient  died  in- 
stantaneously of  heart  failure  from  this  acci- 
dent, the  air  being  introduced  through  a  hol- 
low instrument  which  was  used  in  bringing  on 
the  abortion. 

Of  tetanus  resulting  from  retention  of  mem- 
branes in  the  uterus  I  have  met  with  two  instan- 
ces in  my  experience.  In  such  cases  the  trouble 
commences  in  the  uterus  (arising  from  putrid 
infection),  and  thence  is  transmitted  to  the  nerv- 
ous centres  as  an  ascending  neuritis. 

Sometimes  after  an  abortion  a  portion  of 
membrane  remains  in  the  uterus,  and  if  this 
consists  of  tufted  chorion  its  villi  are  liable  to 
undergo  proliferative  degeneration,  with  the  re- 
sult of  the  formation  of  what  are  known  as 
uterine  hydatids.  With  the  multiplication  of 
these  hydatids  the  uterus  goes  on  increasing  in 
size  until  it  attains  nearly  or  quite  the  propor- 
tions of  the  organ  at  full  term,  and  this  condi- 
tion leads  to  a  great  many  errors  in  diagnosis. 

There  is  only  one  more  consequence  of  abor- 


52  ABORTION  AND  ITS  TREATMENT. 

tion  of  which  I  will  speak — viz.,  chronic  melan- 
cholia— and  this,  like  the  last  five  conditions 
enumerated  in  my  list,  is  very  rare.  This  kind 
of  melancholia  will  be  found  to  run  a  course 
less  severe,  according  to  my  experience,  than 
that  following  labor  at  full  term. 


LECTURE  lY. 

Symptoms  indicathe  of  commencing  abortion — Hemorrhage — • 
Pain — Vomiting — Methods  of  preventing  an  anticipated  abor- 
tion— Nervous  influences  in  the  home-life  of  women — Syphilis 
— Retroflexion — Laceration  of  the  cervix — Fibrous  polypi — 
Large  fibroids — Importance  of  rest  in  bed  at  menstrual  period 
when  a  tendency  to  abortion  is  present — The  habit  of  abortion 
— The  treatment  of  abortion  actually  taking  place — Rule  for 
deciding  whether  or  not  to  attempt  to  stop  a  commencing 
abortion — Methods  of  prevention — Importance  of  absolute 
rest  and  quiet — Use  of  opium,  chloral,  and  bromides — The 
tampon. 

Let  us  suppose  that  a  patient  has  reason  to 
fear  that  abortion  is  about  to  take  place,  and 
that  you  are  summoned  to  attend  her.  What 
are  the  symptoms  that  will  warn  you  that  there 
is  danger  of  the  uterus  expelling  its  contents'? 
There  are  only  three  which  are  of  real  value  and 
which  are  worthy  of  your  especial  consideration. 
They  are  the  essential  symptoms,  and  you  need 
not  pay  attention  to  any  others.  The  first  of 
these  is  haemorrhage,  and  not  pain.     This  pre- 


54  ABORTION  AND  ITS  TREATxMENT. 

cedes  pain,  because  tlie  first  contractions  of  tlie 
uterus  are  so  slight  that  they  do  not  give  rise 
to  any  suffering,  even  although  they  are  suffi- 
cient to  detach  some  of  the  delicate  connections 
between  the  foetal  shell  and  the  uterus. 

The  second  essential  symptom  is  pain.  Af- 
ter the  process  has  gone  on  for  an  hour  or  so  the 
woman  begins  to  feel  an  occasional  bearing-down 
pain,  and  these  pains  increase  in  frequency  and 
severity  as  the  uterine  contractions  increase  in 
force. 

The  third  symptom  to  which  I  would  call 
your  attention  is  vomiting.  This  sign  may,  of 
course,  be  absent ;  but  it  is  curious  to  notice 
how  frequently  it  is  present. 

Now  let  us  consider  the  methods  of  prevent- 
ing an  abortion  which  is  anticipated ;  in  other 
words,  the  manner  of  dealing  with  cases  of  ha- 
bitual abortion.  Perhaps  the  patient,  without 
existing  symptoms  of  abortion,  will  send  for 
you  and  tell  you  that  she  is  one  month  preg- 
nant, and  that  she  regrets  this  exceedingly, 
for  the  reason  that  she  has  had  seven  or  eight 


ABORTION  AND  ITS  TREATMENT.  55 

mishaps,  one  after  the  other,  and  has  never 
given  birth  to  a  living  child.  Or  she  may  in- 
form you  that  she  has  been  married  ten  years 
and  had  a  child  nine  years  ago,  but  since  then 
only  a  number  of  successive  abortions.  These 
abortions  have  always  occurred  between  the  end 
of  the  second  and  the  end  of  the  fourth  month, 
and  she  will  very  probably  say  that  she  has  sent 
for  you  because  she  wants  you  to  prevent  a  re- 
currence now.  Or,  again ;  a  patient  may  state 
that  she  is  not  pregnant  now,  but  that  she  has 
had  a  number  of  abortions,  and  would  like  you 
to  find  out  before  she  becomes  pregnant  again 
what  has  been  the  cause  of  them,  in  order  that 
she  may  prevent  the  next  one  that  threatens. 

In  order  to  suggest  to  you  how  you  are  to 
deal  with  such  cases  as  these  I  venture  to  reca- 
pitulate some  of  the  points  which  have  already 
been  gone  over  in  these  lectures,  begging  your 
indulgence  for  my  acquiescence  in  the  belief  of 
that  French  author  who  thinks  that  the  essence 
of  teaching  is  contained  in  ^'-repetition  sans 
cesse" 


56  ABORTION  AND  ITS  TREATMENT. 

You  should  always  begin  by  examining  the 
woman  very  carefully  as  to  her  general  system. 

See  if  there  be  anything  in  her  occupation 
or  habits  of  life  likely  to  induce  abortion.  In 
other  words,  try  to  find  out  whether  the  cause 
of  the  habitual  abortions  is  maternal,  and  cor- 
rect it  if  it  be  in  your  power  to  do  so.  If  in 
any  case  you  are  not  certain  whether  something 
that  you  may  discover  regarding  the  system  of 
the  mother  is  responsible  for  the  trouble,  give 
her  the  benefit  of  the  doubt,  and  treat  her  as 
if  it  were. 

While  dealing  with  this  part  of  our  subject 
let  me  call  your  attention  to  the  fact  that  there 
are  many  occult  nervous  influences  in  the  home- 
life  of  women  which  are  liable  to  have  more  or 
less  effect  in  causing  abortions.  I  have  in  my 
mind  at  this  moment  a  refined  and  wealthy 
woman  of  this  city  who  is  surrounded  by  every 
luxury,  but  who,  unfortunately,  has  a  husband 
who  is  the  slave  of  alcohol  and  opium,  and,  in 
consequence,  her  life  has  become  almost  unbear- 
able from  his  brutality.     There  are  hundreds  of 


ABORTION  AND   ITS  TREATMENT.  57 

influences  of  this  kind  which  so  disturb  the 
nervous  system  of  the  mother  that  it  is  very- 
difficult  for  her  to  go  to  full  term.  Cases  of 
the  kind  of  which  I  am  now  speaking,  you  will 
find,  are  exceedingly  common. 

If  no  maternal  causes  are  to  be  found,  you 
should  next  look  for  foetal  causes.  If  you  have 
not  attended  the  patient  in  some  of  her  abor- 
tions, communicate,  if  possible,  with  the  physi- 
cians who  treated  her,  and  in  this  way  you  may 
discover  what  the  trouble  has  been.  If  it  is  as- 
certained that  in  previous  abortions  the  product 
of  conception  has  shown  evidences  of  syphilis,  it 
will  be  your  duty  to  treat  the  parent  who  is  at 
fault,  for  this  disease  ;  and,  if  you  can  not  make 
out  which  one  of  them  is  or  has  been  syphilitic, 
to  treat  them  both.  After  twelve  or  fifteen 
months  of  such  antisyphilitic  treatment  you 
will  find  that  there  is  a  strong  probability  that 
the  abortions  may  be  avoided  in  the  future. 

If  you  discover  neither  a  maternal  nor  a  foetal 
cause,  you  must  make  a  careful  examination  of 
the  condition  of  the  uterus.    The  uterine  causes 


58  ABORTION  AND  ITS  TREATMENT. 

of  habitual  abortion  are,  in  fact,  much  more 
important  than  either  the  maternal  (systemic) 
or  the  foetal.  From  the  emphasis  with  which  I  . 
have  spoken  of  this  condition,  you  will  natu- 
rally look  especially  for  retroflexion,  and  it  is  of 
importance  to  bear  in  mind  that  retroflexion 
may  in  certain  cases  exist  just  at  the  period  of 
utero-gestation,  when  the  abortions  commonly 
occur,  and  at  no  other  time.  I  was  strongly 
impressed  with  this  point  very  early  in  my 
obstetrical  practice.  I  was  called  to  attend  a 
patient  w^ho  had  had  nine  abortions,  and  when 
she  became  pregnant  again  I  found  that  the 
uterus  was  in  a  state  of  marked  retroflexion  at 
the  end  of  the  third  month.  I  replaced  the 
organ  and  kept  it  carefully  in  position,  and  the 
result  was  that  she  went  to  full  term  and  was 
delivered  of  a  living  child.  Moreover,  she  after- 
ward had  several  other  children. 

The  mere  perfunctory  putting  in  of  a  pessary 
will  not  be  sufficient  in  these  cases.  You  must 
replace  the  uterus,  and  keep  it  in  position,  for 
if  you  fail  in  this,  the  abortion  will  take  place 


ABORTION  AND  ITS  TREATMENT.  59 

as  before.  It  is  necessary  to  watch  the  uterus 
carefully  every  day  until  the  critical  period  is 
over. 

Among  the  uterine  causes  which  I  have  pre- 
viously mentioned  is  laceration  of  the  cervix. 
Such  lacerations,  as  you  are  perhaps  aware,  are 
capable  sometimes  of  causing  complete  inversion 
of  the  non-pregnant  uterus,  though  such  an  oc- 
currence is  very  rare.  If,  then,  this  condition 
can  produce  such  an  effect  upon  the  non-preg- 
nant uterus,  you  can  readily  appreciate  how 
great  is  the  danger  of  its  giving  rise  to  abortion. 
In  some  cases,  even  a  small  fissure  of  the  os  may 
occasion  so  much  reflex  irritation  that  uterine 
contractions  are  set  up  and  an  abortion  results. 

Another  uterine  cause  is  fibrous  polypi 
within  the  cavity.  You  may  perhaps  have 
noticed  what  a  severe  spasmodic  cough  is  occa- 
sioned by  the  existence  of  a  small  polypus  in 
the  larynx.  Indeed,  wherever  these  growths  are 
situated  they  are  apt  to  set  up  a  considerable 
amount  of  reflex  irritation.  I  once  had  a  pa- 
tient in  my  private  hospital  who  suffered  from 


60  ABORTION  AND  ITS  TREATMENT. 

the  most  violent  spasm  of  the  rectum.  Before 
examining  the  parts  I  supposed  that  the  trouble 
was  probably  due  to  a  fissure  of  the  anus ;  but 
when  I  made  an  examination  I  found  that  there 
was  no  fissure  present,  but  that  just  within  the 
anus  there  was  a  little  fibrous  polypus.  I  re- 
moved this,  and  the  patient  never  had  another 
rectal  spasm.  In  the  same  way  a  polypus  will 
act  upon  the  pregnant  uterus. 

Large  fibroid  tumors,  however,  whether  sub- 
mucous or  interstitial,  are  still  more  likely  to 
cause  abortion,  because  they  exert  more  press- 
ure and  interfere  with  the  innervation  of  the 
organ. 

Here  let  me  impress  one  point  especially 
upon  you.  If  a  woman  abort  at  all,  in  the  vast 
majority  of  instances  the  accident  will  occur  co- 
incidently  with  the  menstrual  epoch.  If,  there- 
fore, you  have  a  patient  under  your  care  who  has 
shown  marked  tendency  to  abort,  you  should 
always  keep  her  strictly  in  bed  for  twelve  days 
out  of  every  month — viz.,  four  days  before  the 
menstrual  period,  four  days  during  the  period, 


ABORTION  AND  ITS  TREATMENT.  61 

and  four  days  after  it.  The  most  perfect  rest 
of  both  mind  and  body  should  be  secured ;  and 
she  should  be  carefully  shielded  against  all  dis- 
turbing influences.  Even  when  the  active  cause 
of  previous  abortions  has  been  discovered  and 
removed,  a  certain  influence  from  this  may  re- 
main for  a  considerable  length  of  time. 

I  regard  confinement  to  bed  as  one  of  the 
most  important  remedies  at  the  command  of  the 
intelligent  physician  in  these  cases. 

When  in  any  given  case  you  have  excluded 
all  maternal,  foetal,  and  uterine  causes,  you  will 
be  forced  to  fall  back  upon  what  I  have  spoken 
to  you  of  as  the  habit  of  abortion  to  explain  the 
difficulty.  This  class  of  cases  seems,  as  far  as  we 
are  able  to  judge,  to  be  due  to  a  hypereesthetic 
condition  of  the  uterine  system  of  nerves  ;  and 
that  is  all  that  we  know  about  the  matter.  The 
diagnosis  is,  of  course,  an  empirical  one,  but, 
under  the  circumstances,  we  can  do  no  better. 
When  you  meet  with  a  patient  of  this  kind 
wait  till  pregnancy  has  advanced  to  the  end  of 
the  sixth  week,  and  then  keep  her  in  bed  until 


62  ABORTION  AND  ITS  TREATMENT. 

the  fifth  month.  In  very  many  cases  you  will 
find  that  this  plan  will  be  successful.  The 
uterus  is  unable  to  perform  its  functions,  and 
therefore  you  must  give  it  rest,  just  as  you 
would  the  other  organs  under  similar  circum- 
stances. 

You  will  be  surprised  to  see  what  good  re- 
sults will  often  follow  this  empirical  treatment. 

I  come  now  to  the  treatment  of  abortion  ac- 
tually in  progress.  We  will  suppose  that  it  is 
just  after  the  third  menstrual  period  in  utero- 
gestation,  and  that  the  process  of  abortion  has 
commenced.  You  find  the  patient  in  bed,  and 
she  probably  tells  you  that  after  taking  a  walk 
or  ride  (during  which  she  made  no  unusual  ex- 
ertion) she  felt  a  sensation  of  moisture,  and,  on 
making  an  examination,  found  that  she  was 
bleeding  freely.  At  the  present  time  she  is  oc- 
casionally having  a  slight  pain. 

What  is  to  be  done  under  these  circum- 
stances ?  You  at  once  ask  yourself  the  question, 
"  Am  I  to  try  to  prevent  this  abortion  from  tak- 
ing place,  or  should  I  endeavor  to  facilitate  the 


ABORTION  AND   ITS  TREATMENT.  63 

process  ? "  This  is  the  question  to  be  decided, 
and  the  decision  must  be  made  at  once,  for  the 
line  of  treatment  adopted  in  the  one  case  will,  of 
course,  be  radically  different  from  that  appli- 
cable to  the  other. 

Let  me  offer  you  a  rule  for  the  decision  of 
this  important  point.  Do  not  allow  yourself 
to  be  persuaded  that  the  amount  of  blood  lost 
shall  be  your  guide.  It  may  be  that  you  will 
find  the  haemorrhage  somewhat  alarming,  and 
the  patient  already  showing  the  usual  signs  de- 
noting a  severe  loss  of  blood.  But  on  this 
account  do  not  conclude  that  the  completion  of 
the  process  of  abortion  is  inevitable. 

Here  let  me  digress  for  a  moment  to  say  that 
it  is  possible  that  the  patient  may  be  unwilling 
to  submit  to  a  vaginal  examination.  If  this  be 
the  case,  take  the  husband  quietly  aside  and 
tell  him  that  such  an  examination  is  absolutely 
necessary  for  the  successful  management  of  the 
case,  and  that  if  it  be  refused  the  responsibil- 
ity for  the  result  will  be  shifted  from  your 
shoulders  to  his,      I  have  never  known  an  in- 


64  ABORTION   AND  ITS  TREATMENT. 

stance  where  an  examination  was  not  willingly 
permitted  after  the  matter  had  thus  been  fully- 
explained. 

Now  for  the  rule  of  which  I  Just  now  spoke. 
If  the  OS  uteri  be  dilated  to  such  an  extent 
that  you  can  pass  your  finger  through  it  and 
touch  the  presenting  foetal  ball,  do  not  fritter 
away  your  own  and  the  patient's  time  by  try- 
ing to  stop  the  process  of  expulsion.  Such  an 
attempt  will  almost  surely  be  useless.  If,  how- 
ever, the  OS  be  not  so  dilated,  it  will  be  your 
duty  to  try  to  stop  the  abortion.  This  is  a  per- 
fectly valid  rule,  because  the  first  stage  of  abor- 
tion is  dilatation  of  the  cervix,  and  if  that  is 
over  there  is  little  chance  of  prevention. 

Next  let  us  consider  the  methods  of  preven- 
tion. Very  often  the  woman  is  told  to  go  to 
bed,  a  full  dose  of  opium  is  ordered,  and  a  bag 
of  ice  is  placed  over  the  fundus  uteri,  for  what 
reason  I  do  not  know.  The  physician  may  or 
may  not  apply  a  tampon,  as  he  sees  fit,  and 
then  he  goes  home.  He  leaves  no  directions 
that  the  light  shall  be  excluded  from  the  apart- 


ABORTION  AND  ITS  TREATMENT.  65 

ment  or  that  the  children,  servants,  or  friends  of 
the  patient  shall  not  have  free  access  to  her.  In 
three  hours,  perhaps,  he  comes  back  "  to  ob- 
serve the  progress  of  the  case." 

I  do  not  regard  this  as  an  efficient  method 
of  preventing  a  threatened  abortion.  My  mean- 
ing may  be  illustrated  by  an  incident  vrhich 
occurred  to  me  a  good  many  years  ago.  I 
was  house  surgeon  in  one  of  the  institutions 
on  Ward's  Island,  and  on  one  occasion  the  vis- 
iting surgeon,  the  late  Dr.  John  M.  Carnochan, 
brought  with  him  to  the  island  the  celebrated 
English  authority  on  nervous  diseases,  Dr.  Mar- 
shall Hall,  who  was  then  on  a  visit  to  this  coun- 
try. At  the  time  I  had  under  my  care  a  man 
who  was  suffering  from  violent  convulsions,  and 
Dr.  Hall  asked  me  how  I  was  treating  him. 
When  I  told  him  that  I  was  applying  sinapisms 
to  the  wrists  and  lower  extremities  and  ice  to 
the  head  and  was  purging  him  with  croton-oil 
(the  recognized  treatment  for  convulsions  at  that 
day),  he  said  to  me,  "Young  man,  let  me  tell 
you  of  an  experience  of  my  own.     Not  long 


66  ABORTION  AND   ITS  TREATMENT. 

since  in  London  I  procured  two  puppies  of 
equal  size  and  appearance  and  poisoned  them 
with  large  doses  of  strychnine.  One  of  them  I 
treated  by  keeping  it  in  the  light  and  making 
counter-irritation  upon  the  external  surface  of 
the  body  by  frictions,  etc.  This  puppy  died. 
The  other  I  put  down  in  a  deep  cellar  which 
was  perfectly  dark  and  absolutely  quiet,  and  left 
him  without  any  treatment  whatever.  The  re- 
sult was  that  this  second  puppy  got  well." 

There  were  thirty  or  forty  students  present, 
and  he  then  gave  a  most  interesting  clinical 
lecture  on  the  case  mentioned,  in  which  he 
dwelt  upon  the  happy  effects  of  complete  rest 
and  the  adoption  of  sedative  methods  in  condi- 
tions of  excitation  of  the  nervous  system.  The 
lesson  which  he  taught  made  a  most  lasting 
impression  upon  my  mind. 

The  proper  way  to  treat  a  threatened  abor- 
tion is,  in  my  judgment,  the  following :  In  the 
first  place,  absolute  rest,  as  far  as  attainable, 
should  be  insisted  upon  as  regards  the  mind 
and  nervous  system  as  well  as  the  body.     The 


ABOKTION  AND  ITS   TREATMENT.  67 

room,  which  should  be  one  of  large  size,  should 
be  kept  darkened  and  in  perfect  silence  and  no 
one  be  allowed  to  enter  it  except  the  nurse  (who 
should  be  secured  at  the  earliest  possible  mo- 
ment), and  perhaps  the  husband  if  his  presence 
tend  to  allay  the  anxiety  of  the  patient.  The 
patient  should  have  complete  freedom  from  all 
outside  cares,  and  her  diet  should  consist  of 
only  the  simplest  food,  such  as  milk  or  beef- 
juice,  so  that  her  stomach  may  have  almost 
nothing  to  do. 

Is  there  any  drug  that  will  be  of  service 
under  these  circumstances  ?  you  ask.  Yes  ;  give 
her  a  full  dose  of  opium,  either  alone  or  in 
combination,  I  am  very  fond  of  using  a  mixt- 
ure which  contains  ten  grains  of  bromide  of 
sodium  or  potassium,  six  or  seven  grains  of 
chloral,  and  one  fifth  of  a  grain  of  morphine  to 
the  dose,  repeating  it  according  to  circum- 
stances. Each  of,  these  agents  produces  quiet 
in  its  own  way — the  chloral  inducing  sleep,  the 
bromide  exerting  its  peculiar  sedative  effect 
upon  the  nervous  system,  and  the  opium  hav- 


68  ABORTION  AND  ITS  TREATMENT. 

ing  that  happy  influence,  which  we  all  know  so 
well,  of  robbing  life  of  its  cares. 

The  first  thing  of  all  to  do,  however,  if  the 
patient  be  bleeding  freely,  is  to  make  use  of 
a  carefully  applied  tampon.  When  you  come 
back  to  see  her  at  the  end  of  three  hours  you 
will  probably  find  that  she  is  in  a  sound  sleep, 
and  she  will  very  likely  sleep  on  for  four  or 
five  hours.  In  twenty-four  hours  the  tampon 
may  be  removed,  but  the  patient  should  be  kept 
perfectly  quiet  until  all  danger  of  a  return  of 
the  trouble  is  over. 


LECTURE  y. 

Treatment  when  expulsion  is  inevitable — Antisepsis  in  abortion — ■ 
Danger  of  infection  from  faecal  matter — The  water-closet  as 
a  source  of  peril — The  tampon  the  remedy  in  abortion — Opium 
and  ergot  both  contra-indicated — How  to  make  and  apply  a 
tampon — The  removal  of  the  tampon — Importance  of  remov- 
ing whatever  remains  of  the  product  of  conception — Method 
of  doing  this — Treatment  of  putrid  infection — Of  septicaemia 
— Of  pelvic  abscess. 

We  come  now  to  the  treatment  of  abortion 
in  cases  in  which  you  have  decided,  in  accord- 
ance with  the  rules  laid  down  in  the  last  lecture, 
that  the  process  of  expulsion  must  necessarily 
take  place.  Finding  the  abortion  inevitable, 
you  have  no  right  to  try  any  longer  to  stop  it. 
It  may  in  certain  cases  be  delayed  for  days  or 
weeks,  or  even  months.  The  placenta,  or  some 
other  portion  of  the  uterine  contents,  may  be 
caused  to  remain,  but,  by  allowing  such  a  thing 
to  occur,  you  expose  your  patient  to  the  immi- 
nent risk  of  death  from  putrid  absorption. 


70  ABORTION  AND  ITS  TREATMENT. 

What  you  want  to  do  is  to  get  the  woman 
through  with  the  abortion  as  quickly  as  possi- 
ble, and  to  leave  no  nidus  for  bacteria  in  the 
uterus  afterward.  And  this  brings  me  to  the 
subject  of  antisepsis,  upon  which  I  wish  to  say 
a  few  words  to  you. 

About  the  importance  of  antisepsis  in  gen- 
eral, and  the  various  methods  and  agents  em- 
ployed for  carrying  this  out  in  practice,  I  can 
not,  of  course,  stop  to  speak  very  fully.  I  take 
it  for  granted  that  every  student  of  this  college 
is  already  perfectly  well  informed  on  these 
points.  I  need  only  say  that  I  am  an  enthu- 
siast on  this  subject,  and  I  trust  that  every  one 
of  you  will  be  so  too. 

Even  as  to  antisepsis  in  abortion,  I  can  not 
go  into  details.  I  only  want  to  fix  in  your 
minds  the  essentials  to  be  remembered.  You 
will  find  that  many  a  man  who  conducts  every- 
thing in  a  truly  antiseptic  manner  when  labor 
occurs  at  full  term,  will  neglect  the  same  pre- 
cautions in  cases  of  abortion.  Yet  it  is  just  as 
important  that  he  should  be  antiseptic  in  the 


ABORTION  AND  ITS  TREATMENT.  71 

latter  as  in  the  former.  At  this  time,  as  some 
German  writer  has  expressed  it,  the  uterus 
moults  its  mucous  membrane  as  a  bird  its 
feathers  ;  and  what  better  culture  fluid  for  nox- 
ious bacteria  could  you  possibly  have  than  this  ? 

Let  us  glance  at  the  general  means  for  pre- 
venting the  entrance  and  development  of  bac- 
teria. In  the  first  place,  you  must  be  thorough- 
ly aseptic  yourself.  You  should  not  come  to  a 
woman  having  an  abortion,  directly  from  a  case 
of  puerperal  septicaemia,  or  other  infectious 
trouble,  with  your  person  saturated  with  its 
poison.  Your  clothes,  hands,  instruments, 
sponges,  and  tampon  (if  you  use  the  latter) 
should  all  be  aseptic.  It  is  essential,  also,  that 
the  nurse  should  be  thoroughly  aseptic  as  to 
her  clothes,  her  hair,  her  hands,  and  especially 
her  finger-nails. 

!N'ext,  the  patient  should  be  rendered  aseptic 
as  well.  Even  in  women  who  have  never  suf- 
fered a  laceration  of  the  perinseum  the  distance 
between  the  vulva  and  anus  is  exceedingly  short, 
and  in  those  who  have  met  with  this  accident 


72  ABORTION  AND  ITS  TREATMENT. 

this  normal  distance  is  more  or  less  diminished. 
Now,  as  faecal  matter — which  is,  as  you  know, 
highly  septic — is  repeatedly  passing  from  the 
anus,  yoa  can  readily  appreciate  how  constant 
and  how  great  is  the  danger  of  infection  arising 
from  this  source.  The  best  of  the  German  au- 
thorities hold  that  it  is  through  the  vulva  that 
puerperal  septicaemia  is  ordinarily  contracted. 

It  is  of  the  utmost  importance,  therefore, 
that  the  vulva  and  anus  should  be  thoroughly 
bathed  with  some  antiseptic  fluid.  If  bichloride 
solution  be  used,  it  should  be  of  the  strength  of 
about  1  to  2,000. 

I  insist  strongly  on  this  point,  for  the  reason 
that  so  little  attention  has  been  paid  to  the  mat- 
ter. You  will  not  find  it  mentioned  in  any  of 
the  older  books ;  but  I  feel  assured  that  it  will 
not  be  omitted  in  the  next  work  on  obstetrics. 
It  is  true  now,  as  always,  that  we  are  mending 
the  faults  of  yesterday  by  the  wisdom  of  to-day. 

Let  me  mention  a  case  in  illustration.  Three 
or  four  years  ago  I  was  summoned  to  see,  in 
consultation  with  an  excellent  and  thoroughly 


ABORTION  AND  ITS  TREATMENT.  73 

well-informed  physician,  a  graduate  of  this  col- 
lege, a  wealthy  lady  residing  in  a  flourishing 
town  some  ten  miles  from  New  York.  She  had 
had  a  perfectly  normal  labor,  but  was  now  suf- 
fering from  a  decided  attack  of  puerperal  fever. 
I  questioned  the  physician  thoroughly  upon 
every  point  likely  to  afford  a  clew  to  the  origin 
of  the  trouble,  but  for  a  long  time  my  efforts  at 
finding  out  the  source  of  difficulty  were  entirely 
unsuccessful.  The  doctor  was  constantly  at- 
tending cases  of  midwifery,  but  had  not  had 
a  single  one  in  which  there  was  any  signs  of 
3eptic8emia.  In  attending  this  lady  he  had 
taken  the  greatest  care  in  regard  to  the  condi- 
tion of  his  clothing,  his  hands,  and  his  instru- 
ments. The  nurse  also  was  thoroughly  aseptic, 
and  every  possible  precaution  that  he  could 
think  of  was  taken.  Believing,  as  I  do,  that 
puerperal  septicaemia  is  due  to  a  special  poison 
communicated  from  some  septic  source,  I  began 
to  feel  very  much  puzzled. 

I  inquired  where  the  water-closet  was,  and 
found   that  it  adjoined  the  lying-in  chamber, 


74  ABORTION  AND  ITS  TREATMENT. 

and  that  it  was  one  of  the  old-fashioned  pan 
closets  still,  unfortunately,  so  much  in  vogue. 
In  speaking  of  these.  Colonel  Waring,  one  of 
our  best  authorities  in  matters  of  sanitation, 
says :  "  Everything  looks  like  a  whited  sepul- 
chre above,  but  below  there  is  a  chamber  of 
horrors ! "  I  lifted  the  pan,  and  a  horrible 
odor  assailed  my  nostrils  !  On  further  inquiry, 
I  found  that  the  patient  had  been  in  labor  for 
twelve  hours,  and  that  during  this  time  she 
had  had  three  or  four  passages,  each  time  going 
into  the  water-closet  for  the  purpose.  Now, 
at  last,  light  began  to  break  in  upon  the  aeti- 
ology of  the  case.  Just  think  of  the  position 
of  a  woman  in  the  act  of  defecation  or  urina- 
tion. With  the  downward  pressure  brought  to 
bear,  the  labia  are  rolled  out  and  the  vaginal 
walls  widely  unfolded.  Up  from  below,  to  come 
in  contact  with  all  this  unfolded  surface  of  mu- 
cous membrane,  rise  the  emanations  from  the 
closet  loaded  with  septic  germs  !  Here  was  a 
woman  in  the  pains  of  labor  subjecting  herself 
directly  to  the   poison   of   the  sewer-pipe,  for 


ABORTION  AND  ITS  TREATMENT.  ^5 

probably  at  least  five  minutes  at  a  time,  several 
times  during  the  process  of  labor! 

When  I  considered  these  circumstances  I  no 
longer  felt  any  doubt  as  to  the  causation  of  the 
disease.  Can  you  question  the  correctness  of 
this  opinion  as  to  its  origin  when  you  reflect 
that  the  air  and  moisture  that  came  in  contact 
with  the  vulva  and  vagina  were  permeated  with 
every  factor  instrumental  in  the  production  of 
puerperal  septicaemia? 

Strange  to  say,  this  danger  is  not  referred 
to  in  any  book  or  monograph  in  any  language, 
so  far  as  I  am  aware.  It  is  therefore  all  the 
more  important  that  you  should  get  here  the 
lesson  which  this  and  similar  cases  teach.  That 
lesson  is  this  :  during  abortion,  or  labor  at  term, 
never  permit  a  patient  to  use  anything  but  the 
ordinary  chamber-vessel  or  commode  for  alvine 
evacuations  ! 

I  regard  it  as  a  point  of  the  utmost  impor- 
tance. Up  to  the  present  day  nearly  all  the  best 
hotels  in  the  city  of  New  York  are  still  provided 
with  these  old-fashioned  pan  closets,  often  im- 


^6  ABORTION  AND  ITS  TREATMENT. 

mediately  adjoining  the  sleeping  apartments  ; 
and  any  lady  who  is  taken  with  an  abortion 
and  nses  one  of  them  is  exposed  to  the  danger 
of  which  I  speak.  In  dismissing  this  subject  I 
may  say  that  the  patient  whose  case  I  have 
narrated  finally  recovered,  although  for  a  time 
she  was  at  death's  door,  and  for  months  after- 
ward was  ill  with  the  worst  sequelae  of  puerpe- 
ral septicaemia. 

Suppose  that  the  abortion  is  going  on,  and 
that  the  woman  is  losing  large  quantities  of 
blood.  What  is  to  be  done  ?  You  feel  that 
you  can  not  spare  the  time  to  remain  all  day 
to  look  after  the  case,  and  yet  it  is  manifestly 
risky  to  leave  the  patient.  Under  these  circum- 
stances have  we  any  efficient  remedy  which  can 
always  be  depended  upon  ?  When  you  hear  of 
a  large  number  of  remedies  for  any  affection 
you  may  rest  assured  that  there  is,  strictly 
speaking,  no  remedy  for  it.  This  is  the  case, 
for  instance,  as  regards  whooping-cough,  for 
which  there  is  no  specific.  But  we  have  a 
specific  remedy  for  malarial  fever  and  we  have 


ABORTION  AND  ITS  TREATMENT.  77 

one  for  syphilis.  So,  too,  we  have  a  remedy 
for  abortion,  and  that  is  the  tampon !  This  is 
the  one  great  remedy,  and  it  will  serve  you 
well.  In  the  early  period  of  abortion  there  is 
but  one  danger;  that  is  haemorrhage.  When 
you  have  properly  applied  an  efficient  tampon 
you  can  leave  your  patient  in  perfect  security. 
The  tampon  controls  the  bleeding  entirely,  and 
allows  the  process  to  go  on  to  a  successful  ter- 
mination without  danger. 

When  you  return  to  the  house  six  or  eight 
hours  afterward  the  j^atient  will  often  tell  you 
that  she  feels  perfectly  well.  From  the  nurse 
you  learn  that  there  has  been  no  haemorrhage 
whatever,  and  when  you  come  to  take  away 
the  tampon  you  will  perchance  find  following 
it  the  entire  foetal  shell,  unbroken  if  the  period 
is  early  in  utero-gestation,  or  the  foetus  M^ith  the 
membranes  and  placenta  if  later.  You  then 
have  the  vulva  bathed,  not  using  a  vaginal  in- 
jection, and  apply  an  antiseptic  pad. 

But,  you  may  ask,  if  the  patient  suflfers 
much  pain  before  the  expulsion  of  the  fof^tus. 


78  ABORTION  AND  ITS  TREATMENT. 

should  we  not  relieve  it  with  opium  ?  Certainly 
not.  These  pains  are  just  what  are  requisite  to 
complete  the  work  of  expulsion,  and  should  not 
be  interfered  with.  You  might  as  well  fasten  a 
ball  and  chain  to  your  leg  when  you  are  about 
to  start  to  run  in  a  race !  Neither,  on  the  other 
hand,  should  you  use  ergot.  To  do  so  while 
the  OS  is  still  undilated  would  be  entirely  un- 
philosophical,  as  I  have  had  occasion  to  remark 
previously.  What,  then,  should  you  do  for  the 
patient  ?  Nothing  whatever  if  the  tampon  is 
properly  applied!  Tt  is  highly  important  that 
you  should  remember  that  the  tampon  is  the 
remedy  in  abortion,  and  in  the  vast  majority  of 
instances  it  will  do  its  work  in  a  perfectly  satis- 
factory manner.  With  the  tampon  in  position, 
you  may  go  about  your  work,  feeling  perfect- 
ly at  ease.  Your  main  duty  consists  in  not 
interfering.  Nature  is  perfectly  competent  to 
carry  on  her  work  to  completion  without  your 
aid. 

Let  me  teach  you  how  to  make  a  tampon. 
Get  some  good  cotton  or  cotton  batting,  and 


ABORTION  AND  ITS  TREATMENT.  79 

divide  it  into  twenty-five  or  tMrty  fiat  pieces, 
two  and  a  half  or  three  inches  in  diameter. 
Then  prepare  some  carbolic-acid,  solution,  of  the 
strength  of  about  five  per  cent— the  most  con- 
venient way  of  doing  this  is  by  the  nse  of  the 
tablets  which  you  can  find  in  all  the  shops — 
and,  having  put  a  number  of  your  pieces  of 
cotton  into  it,  boil  it  thoroughly.  In  carbolic 
acid  and  the  boiling  process  you  have  two  of 
the  best  antiseptics  known  to  science.  Care 
must  be  taken,  however,  not  to  have  the  anti- 
septic solution  too  strong. 

When  you  are  ready  to  apply  the  tampon, 
have  a  table  brought  to  the  side  of  the  bed, 
with  a  pillow  and  blanket  upon  it.  The  patient 
should  lie  upon  this  table  in  the  Sims  position, 
with  one  arm  thrown  back  so  that  the  left 
pectoral  muscles  touch  the  table.  The  best 
material  for  the  packing  of  the  upper  part  of 
the  vagina  is  iodoform  gauze  ;  but  if  this  can 
not  be  obtained,  use  some  of  your  antiseptically 
prepared  cotton,  after  first  squeezing  it  as  dry 
as  possible  by  putting  it  between  the  folds  of 


80  ABORTION  AND  ITS  TREATMENT. 

a  towel  and  forcibly  slapping  it.  If  tlie  os  be 
open,  stuff  some  of  the  dressing  into  it ;  then 
you  should  pack  the  posterior  cul-de-sac^  and 
then  the  anterior  cul-de-sac.  This  should  all 
be  done  with  iodoform  gauze,  if  you  can  get  it ; 
and  below  this  you  pack  in  three  or  four  pieces 
of  antiseptic  cotton  for  the  purpose  of  keeping 
the  upper  dressing  in  jDlace  and  protecting  the 
vagina  from  septic  influences.  It  is  not  bac- 
teria in  general  which  are  likely  to  do  harm, 
but  a  particular  form  of  microbe,  known  as  the 
streptococcus^  which  is  believed  by  most  au- 
thorities to  be  the  causative  agent  of  puerperal 
septicaemia.  I  have  yet  to  see  from  this  method 
of  treatment  one  solitary  case  of  poisoning  from 
carbolic  acid,  though  I  would  particularly  im- 
press upon  you  the  necessity  of  beating  out  the 
cotton  wet  with  the  solution  as  dry  as  possible. 
In  these  cases  I  usually  employ  mercuric  bi- 
chloride as  an  antiseptic,  but  I  prefer  to  recom- 
mend carbolic  acid  for  general  use  in  a  course 
of  lectures  like  this. 

When  you  remove  the  tampon  it  is  well  to 


ABORTION  AND  ITS  TREATMENT.  81 

Tise  cotton  soaked  in  carbolic  solution  for  cleans- 
ing the  parts  rather  than  sponges ;  especially  as 
it  is  sometimes  difficult  to  get  good  sponges. 
Having  done  this  thoroughly,  you  can  put  in 
a  new  tampon,  if  this  be  necessary.  The  vulva 
may  be  washed  with  bichloride  solution,  but  it 
should  at  once  be  wiped  perfectly  dry,  for  the 
bichloride,  if  left  long  in  contact  with  the  ex- 
ternal parts,  is  very  apt  to  give  rise  to  eczema 
of  the  most  violent  character.  If  you  employ 
this  agent  you  should  then  bathe  the  vulva 
with  a  five-per-cent  solution  of  carbolic  acid 
or  creoline,  and  apply  an  antiseptic  pad  con- 
sisting of  carbolized  cotton. 

This,  held  in  position  by  a  bandage  con- 
nected with  one  passed  around  the  waist,  pre- 
vents the  access  of  air,  or  at  least  renders  the 
air  aseptic. 

In  the  great  majority  of  instances  you  will 
thus  have  brought  your  case  of  abortion  to  a 
successful  conclusion.  Let  us  suppose,  how- 
ever, that  you  fail  in  this,  the  foetal  shell  or 
some  portion  of  the  membranes  or  placenta  still 


82  ABORTION  AXD   ITS  TREATMENT. 

remaining  in  the  uterus  after  the  expulsive 
pains  have  ceased.  You  wait  three  or  four 
days,  and  still  the  process  of  emptying  the 
uterus  has  not  been  completed.  In  the  mean 
while  all  pain  and  all  haemorrhage  have  stopped, 
and  the  patient  feels  jjerfectly  well.  There  is, 
in  my  opinion,  nothing  more  censurable  in 
medicine  than  "  making  mountains  out  of  mole- 
hills"; but  in  this  case,  while  everything  ap- 
pears to  be  entirely  normal  and  there  is  noth- 
ing in  the  outward  appearance  of  the  patient 
to  excite  the  slightest  suspicion  of  alarm,  the 
woman  is  really  in  imminent  danger  until  the 
uterus  has  been  thoroughly  and  completely 
emptied.  There  is  no  question  in  my  mind 
about  the  i)ropriety  of  at  once  removing 
whatever  remains  of  the  product  of  concep- 
tion. By  leaving  it  retained  in  the  uterus 
you  will  be  exposing  the  woman  to  great 
risk.  There  could  be  no  better  nidus  for  the 
development  of  putrid  intoxication  or  puer- 
peral septicaemia,  and  if  she  recover,  it  will  be 
in   spite   of   your   criminal    negligence.      It  is 


ABORTION  AND  ITS  TREATMENT.  83 

simply  a  death-trap  that  you  leave  within  the 
uterus ! 

Under  these  circumstances  do  not  consult  the 
friends ;  do  not  ask  for  a  medical  consultation ! 
After  labor  at  full  term  you  would  not  think 
of  allowing  a  retained  placenta  to  remain ;  and 
there  is  no  reason  why  you  should  act  differ- 
ently now.  You  should  tell  the  patient  and 
her  friends  that  the  after-birth  has  not  come 
away,  and  that  it  is  necessary  to  remove  it.  If 
their  consent  is  withheld,  the  responsibility  of 
the  case  is  with  them.  There  will  rarely  be 
any  difficulty  about  the  matter,  however,  when 
you  have  fully  and  frankly  explained  the  cir- 
cumstances. 

Having  placed  the  patient  on  a  table  in  the 
Sims  position,  and  an  anaesthetic  (preferably 
ether)  having  been  administered  by  an  assistant, 
the  speculum  is  held  by  the  nurse,  or  other 
attendant,  and  the  vagina  swabbed  out  with  a 
l-to-2,000  bichloride  solution.  Then,  with  a 
tenaculum  firmly  hooked  into  it,  you  pull  down 
the  posterior  lip  of  the  cervix  and  remove  the 


84  ABORTION  AND  ITS  TREATMENT. 

retained  secundines  with  an  ordinary  large  cu- 
rette. In  the  mean  time  if  pressure  be  made 
over  the  fundus  by  one  of  the  attendants,  you 
will  be  amazed  to  find  how  quickly  the  uterine 
contents  will  roll  out. 

If  the  OS  be  not  sufficiently  dilated  for  the 
purpose,  you  must  stretch  it  more  widely  open 
by  means  of  Goodell's  dilator,  which  acts  on 
the  principle  of  a  glove-stretcher.  You  need 
not  be  afraid  that  this  will  do  harm.  You 
will  sometimes  need  a  small  pair  of  forceps  to 
assist  in  withdrawing  the  foetal  shell  when  ar- 
rested by  the  internal  os.  After  the  uterus  has 
been  completely  emptied  you  should  wash  out 
its  cavity  with  bichloride  solution  or  carbolized 
water  by  means  of  a  catheter  or,  better,  by  Ly- 
man's irrigator,  attached  to  the  tube  of  a  fount- 
ain syringe  and  carried  to  the  fundus.  With 
the  Lyman  instrument  there  is  no  danger  what- 
ever of  the  fluid  being  forced  into  the  Fallopian 
tubes. 

Ordinarily,  you  will  have  no  further  trouble 
with  the  case.     But  let  us  suppose  that  putrid 


ABORTION  AND   ITS  TREATMENT.  85 

infection  should  ensue ;  whicli,  you  will  remem- 
ber, is  quite  a  different  matter  from  puerperal 
septicaemia.  Having  removed  all  retained  se- 
cundines  in  the  manner  already  described,  you 
should  carry  a  stream  of  warm  carbolized  water 
(say  at  a  temperature  of  from  104"  to  106°  F.)  up 
into  the  uterus  by  means  of  a  fountain  syringe. 
If  you  have  no  fountain  syringe,  use  an  ordi- 
nary Davidson  syringe,  and  if  you  have  no 
Davidson  syringe,  take  some  rubber  tubing  and 
make  a  siphon  of  it,  immersing  one  end  in  a 
bucket  containing  the  antiseptic  fluid  placed  at 
a  suitable  elevation. 

If  the  case  be  one  of  true  septicaemia,  put 
the  patient  on  a  table  and  with  the  curette  go 
to  the  fundus  and  completely  clear  out  the  uter- 
ine cavity  of  everything  in  it.  If  it  contains 
nothing  else,  it  will  be  sure  to  have  some  of  the 
flaking  decidua  nera  upon  its  walls,  for  every 
uterus  that  has  not  been  scraped  has  after 
abortion  a  certain  amount  of  this  material 
in  it. 

Then  wash  out  the  cavity  as  in  the  other 


86  ABORTION  AND  ITS  TREATMENT. 

case,  and  you  will,  as  a  rule,  soon  see  good 
results. 

If  you  leave  the  uterus  unemptied  you  allow 
a  nidus  in  wliich  the  deadly  streptococcus  may 
flourish.  Your  antiseptic  washes  will  do  but 
little  good  unless  you  first  remove  the  dead 
membrane,  which  prevents  them  from  acting 
directly  on  the  uterine  walls.  Any  pieces  of 
the  fcEtal  shell  or  of  the  placenta  that  remain 
should  also  be  taken  away,  and  there  is  noth- 
ing better  for  this  purpose  than  the  curette. 
Be  sure  that  you  scrape  the  whole  surface  of 
the  cavity,  and  if  you  can  not  get  well  up  into 
the  horns  with  the  ordinary  large  curette,  take 
a  smaller  instrument  for  this  part. 

What  pathological  danger  now  most  promi- 
nently threatens  your  patient?  She  may  pos- 
sibly have  tetanus,  or  embolism,  or  suppurative 
arthritis ;  but  these  conditions  are  so  rare  as 
to  be  only  the  curiosities  of  abortion,  and  it  is 
therefore  sufficient  that  you  should  be  aware 
of  the  fact  that  such  affections  do  occasionally 
result. 


ABORTION  AND  ITS  TREATMENT.  87 

Before  the  patient  gets  well,  however,  she 
may  have  further  trouble  still.  You  may  find 
her  perhaps  complaining  of  pelvic  pain,  with  a 
pulse  of  120  and  temperature  of  103°  F.,  and 
discover  that  she  has  had  a  violent  chill.  On 
making  an  examination  you  may  find  on  one 
side,  between  the  layers  of  the  broad  ligament, 
a  mass  of  considerable  size  which  may  or  may 
not  yield  a  sense  of  fluctuation.  This  is  a 
"phlegmon,"  or  areolar  inflammation.  The 
condition  is  very  common  following  abortion. 
Whenever  you  find  a  mass  the  size  of  a  hen's 
egg  which  has  formed  in  the  pelvis  within  ten 
days  after  abortion,  you  may  feel  pretty  confi- 
dent that  it  contains  pus.  It  is  easy  to  open 
such  an  abscess,  but  you  will  find  great  diffi- 
culty in  securing  drainage.  The  trouble  is  to 
keep  the  wound  in  the  vagina  open.  Let  me 
show  you  a  very  simple  drainage-tube  which 
I  have  used  for  years  with  very  satisfactory 
results.  The  vagina  should  first  be  washed 
out  with  a  carbolic  solution.  Then,  an  assist- 
ant making  pressure  on  the  tumor  from  above, 


88  ABORTION  AND  ITS  TREATMENT. 

the  patient  lying  upon  the  back,  you  should 
place  your  finger  upon  its  lowest  point  in  the 
vagina.  Taking  care  to  avoid  any  arteries 
(which  can  readily  be  felt),  you  now  slip  the 
point  of  a  pair  of  long,  curved  scissors  along 
the  finger  and  "gnaw"  your  way  into  the 
mass,  without  cutting.  When  absence  of  re- 
sistance tells  you  that  you  have  got  to  the 
centre  of  the  mass,  pus  will  flow  out.  Now 
for  our  drainage-tube.  Taking  an  ordinary 
soft-rubber  tube,  I  cut  it  down  for  a  short  dis- 
tance on  either  side,  say  about  one  inch,  mak- 
ing two  lips  of  equal  size.  With  a  needle  a 
thread  is  then  passed  through  the  center  of 
the  tube,  through  the  lips  on  either  side,  and 
through  the  tube  again,  a  short  distance  be- 
low, and  then  tied  in  such  a  manner  as  to  hold 
the  lips  at  right  angles,  but  with  sufficient 
looseness  to  allow  them  to  close  when  resist- 
ance is  encountered  in  making  traction  upon 
the  tube.  When  the  drainage-tube  thus  pre- 
pared is  to  be  inserted,  the  two  lips,  bent 
downward,   are  grasped  with  forceps  and  the 


ABORTION  AND  ITS  TREATMENT.  89 

tube  is  carried  up  into  position.  When  the 
forceps  are  withdrawn,  the  tube  will  be  held  in 
place  by  the  gaping  lips,  which  rest  lightly  on 
the  edges  of  the  wound ;  and  when  you  wish 
to  take  it  out  you  have  simply  to  make  trac- 
tion upon  it,  when  the  resistance  encountered 
from  the  edges  of  the  wound  will  cause  the 
lips  to  close,  and  the  tube  will  readily  slip  out. 


LECTURE  yi. 

Remote  results  of  abortion — Uterine  hydatids — Suppurative  ar- 
thritis— Tetanus — Melancholia — Septic  peritonitis — Chances 
of  error  in  connection  with  abortion — Twin  conception — 
Extra-uterine  foetation — Uterine  hydatids — "  Molar  preg- 
nancy " — Difficulty  of  the  diagnosis  of  pregnancy — Artificial 
production  of  abortion — Deception  on  the  part  of  patients — 
Necessity  for  a  consultation  before  inducing  abortion — Indi- 
cations for  the  artificial  induction  of  abortion — Methods  of 
producing  abortion — Improper  methods — Danger  of  uterine 
tents — The  best  method. 

In  the  last  lecture  we  spent  some  time  in 
considering  the  immediate  results  following 
abortion.  Let  us  now  glance  at  some  of  the 
more  remote  ones.  Among  these,  as  I  have 
told  you,  uterine  hydatids  may  occasionally  be 
met  with.  This  condition  is  simply  the  result 
of  cystic  degeneration  of  portions  of  retained 
chorion.  The  conduct  of  the  case  is  simple 
when  once  the  diagnosis  has  been  made ;  and, 
as  in  the  case  of  tape- worm,  the  diagnosis  can 


ABORTION  AND  ITS  TREATMENT.  91 

only  be  established  by  ocular  demonstration. 
To  determine  the  presence  of  tape-worm  it  is 
essential  that  some  portion  of  the  parasite 
should  be  seen ;  and  to  make  out  the  diag- 
nosis of  hydatids  it  is  necessary  that  some  of 
the  hydatids  should  be  seen.  Having  once 
made  the  diagnosis,  you  have  only  to  empty 
the  uterus  as  you  would  in  the  case  of  any 
other  retained  matters. 

Next,  as  to  suppurative  arthritis.  Patholo- 
gists are  still  at  variance  as  to  the  distinction 
between  pysemia  and  septicaemia.  I  think  that 
we  are  safe  in  saying  that  septicaemia  is  a  con- 
dition which,  if  it  continues  long  enough,  may 
end  in  pysemia.  As  a  result  of  the  former,  sep- 
tic embolism  is  apt  to  occur  in  the  small  ves- 
sels of  the  liver,  lungs,  spleen,  and  synovial 
cavities,  and  pysemic  abscesses  may  form  in  the 
joints.  In  such  cases  we  have  simply  a  sep- 
ticaemia which  has  terminated  in  thrombosis  and 
embolism.  The  best  treatment  for  suppurative 
arthritis  I  believe  to  be  the  opening  of  the  affected 
Joints,  under  strict  antiseptic  precautions. 


92  ABORTION  AND  ITS  TREATMENT. 

In  regard  to  tetanus  I  have  nothing  to  say. 
It  is  a  very  rare  result,  and  when  it  occurs  it 
should  be  treated  in  the  same  manner  as  teta- 
nus due  to  any  other  cause. 

We  come  next  to  melancholia.  It  is  proba- 
ble that  many  will  be  inclined  to  dispute  this 
condition  as  one  of  the  results  of  abortion ;  but 
I  have  seen  melancholia  (sometimes  of  a  very 
severe  grade)  following  abortion  sufficiently 
often  to  feel  convinced  that  this  is  one  of  the 
sequelae  that  should  be  apprehended.  As  to 
the  treatment  of  this  condition,  I  can  only  refer 
you  to  works  on  mental  disease,  in  which  the 
management  of  melancholia  in  general  is  fully 
considered. 

Finally,  we  come  to  septic  peritonitis.  In 
abortion  women  sometimes  die  of  haemorrhage, 
and,  as  a  rule,  though  not  invariably,  this  oc- 
curs in  criminal  abortion.  Again,  the  woman 
may  die  in  consequence  of  air  getting  into  the 
veins.  The  vast  majority  of  deaths,  however, 
occur  from  puerperal  septicaemia.  How,  then, 
shall  this  condition  be  treated  when  met  with  1 


ABORTION  AXD  ITS  TREATMENT.  93 

By  two  means,  and  only  two.  As  soon  as  the 
diagnosis  is  made,  put  yonr  patient  in  the 
Sims  position,  and,  having  etherized  her,  with 
thorough  antiseptic  precautions  clear  out  the 
cavity  of  the  uterus  with  a  dull  wire  curette. 
In  order  to  do  this  satisfactorily  it  will  proba- 
bly be  necessary  to  dilate  the  os ;  but  this  can 
be  accomplished  with  perfect  safety  in  a  few 
minutes  by  means  of  the  divulsor.  You  should 
use,  first,  a  large  curette,  and  then  a  smaller 
one,  so  as  to  get  well  up  into  the  cornua,  and, 
if  possible,  even  into  the  entrance  of  the  Fal- 
lopian tubes.  Then,  by  means  of  the  douche 
which  I  showed  you  at  our  last  meeting,  wash 
out  the  uterine  cavity  with  creoline,  carbolic- 
acid  solution,  or  a  weak  bichloride  solution.  I 
would  not  advise  you  to  use  the  bichloride  in 
the  uterine  cavity  stronger  than  in  the  propor- 
tion of  one  to  three  or  four  thousand. 

If  you  have  curetted  thoroughly,  you  will 
be  surprised  to  find  how  quickly  the  tempera- 
ture will  come  down  as  soon  as  you  commence 
the  douche.      Having  thus    reduced    the    tem- 


94:  ABORTION  AND  ITS  TREATMENT. 

perature,  you  sliould  treat  the  case  according 
to  the  conditions  present,  bearing  in  mind  the 
general  principles  which  have  been  previously 
laid  down. 

We  pass  now  to  the  consideration  of  certain 
chances  of  error  which  may  arise  in  connection 
with  abortion,  and  at  the  outset  I  will  remark 
that  I  want  you  to  remember  always  that  even 
the  best  of  men  may  sometimes  be  deceived. 

A  woman  has  an  abortion,  say,  at  the  end 
of  the  third  month.  The  foetus  and  the  pla- 
centa come  away,  and  the  decidua  mra  is  car- 
ried off  in  the  lochial  discharge  that  follows. 
The  uterus  has  apparently  cleansed  itself  thor- 
oughly. When  her  next  period  arrives,  how- 
ever, the  woman  does  not  menstruate ;  and  this 
is  the  case  at  the  next  period,  and  the  next. 
At  the  end  of  six  months,  she  is  delivered  of 
a  fully  -  developed  living  child.  Wow  if  you, 
as  the  medical  attendant,  are  not  prepared  for 
this  contingency,  you  may  be  placed  in  a  very 
false  position.  I  have  had  such  a  thing  occur 
no  less  than  three  times  in  my  own  experience. 


ABORTION  AXD  ITS  TREATMENT.  95 

Under  these  circumstances  the  friends  of  the 
patient  will  be  very  likely  to  inform  you,  with 
an  air  of  superiority,  that  she  never  had  an 
abortion  at  all.  The  explanation  of  this  is,  that 
one  of  a  pair  of  twins  has  been  cast  off  and  the 
other  has  gone  to  full  term. 

I  can  tell  you  a  worse  case  than  this,  how- 
ever. A  woman  has  an  abortion,  and  the  foetus 
is  cast  off  with  all  its  membranes  entire.  Un- 
der the  circumstances,  you  naturally  congratu- 
late your  patient  on  the  happy  result  of  her 
trouble.  In  a  month,  however,  you  are  sent 
for  in  great  haste,  and  you  arrive  to  find,  to 
your  horror,  that  the  woman  is  in  articulo 
mortis.  A  few  minutes  more  and  she  dies  in 
collapse.  An  examination  shows  that,  in  addi- 
tion to  the  foetus  in  utero,  there  has  been  an 
extra-uterine  one,  and  the  fatal  result  was  due 
to  rupture  of  the  Fallopian  tube. 

There  are  two  other  contingencies,  also, 
which  may  place  you  in  a  false  position.  One 
is  the  following :  The  foetus  is  cast  off,  and  you 

think  that  all  the  membranes  have  come  away 

7 


96  ABORTION  AND  ITS  TREATMENT. 

also.  The  next  month,  however,  the  patient  does 
not  menstruate,  and  then  you  say  that  there  has 
been  a  twin  conception,  and  while  one  of  the 
foetuses  has  been  expelled  the  other  still  re- 
mains in  utero,  and  will  probably  go  to  full 
term.  About  the  end  of  the  ninth  month,  sure 
enough,  the  uterus  does  begin  to  contract ;  but, 
instead  of  a  living  child  being  delivered,  a 
bucketful  of  hydatids  is  cast  out.  These  little 
cysts  of  the  chorion  cling  to  the  uterine  walls 
as  ivy  clings  to  the  oak,  and  they  go  on  de- 
veloping and  multiplying  to  such  an  extent 
that  the  cavity  becomes  more  and  more  en- 
larged to  accommodate  them,  and  not  infre- 
quently the  uterus  grows  to  the  size  of  the 
organ  at  full  term. 

The  other  contingency  is  this :  The  foetus 
is  cast  off,  and  with  it  comes  a  considerable 
quantity  of  blood.  You  examine  the  clots 
and  find  portions  of  the  secundines,  and  you 
are  therefore  induced  to  tell  the  patient  that 
everything  is  over.  The  fact  is,  however,  that 
the  lower  portion  of  the  foetal  shell  has  given 


ABORTION  AND  ITS  TREATMENT,  97 

way  and  the  foetus  has  come  out,  with  a  small 
portion  of  the  membranes ;  leaving  the  re- 
mainder of  the  shell  still  in  utero.  This  shell 
may  remain  for  months  or  years,  constituting 
what  is  known  as  a  "molar  pregnancy."  In  one 
instance  I  knew  it  to  remain  for  twenty  years, 
the  mass  in  the  mean  time  having  undergone 
calcareous  degeneration. 

You  will  find  in  the  community  in  general 
very  positive  ideas  regarding  pregnancy.  Peo- 
ple think  that  a  medical  man  ought  to  know  at 
once  whether  a  woman  is  pregnant  or  not, 
under  all  circumstances.  In  fact,  however, 
the  diagnosis  of  pregnancy  in  the  early  stages 
is  often  one  of  the  most  difficult  that  the 
physician  is  called  upon  to  make.  Still  fur- 
ther, it  is  by  no  means  always  easy  to  make 
the  diagnosis  even  at  a  later  period  ;  and  every 
now  and  then  a  pregnant  uterus  is  cut  down 
upon,  under  the  supposition  that  it  is  an  ovarian 
tumor— often  by  most  excellent  and  careful  phy- 
sicians. 

We  now  come  to  the  consideration  of   the 


98  ABORTION  AND  ITS  TREATMENT. 

question  of  the  artificial  production  of  abor- 
tion. 

In  regard  to  bringing  on  abortion  artifically 
you  will  have  to  be  constantly  on  your  guard, 
or  else  you  will  sometimes  be  imposed  upon. 
All  women  may  be  divided  into  two  great 
classes — those  who  desire  to  bear  children,  and 
those  who  do  not.  It  is  among  the  latter  class 
that  you  will  have  to  look  out  for  deception. 
For  instance,  individuals  of  this  class  have 
been  known  to  take  small  and  repeated  doses 
of  tartar  emetic  in  order  to  produce  such  con- 
stant and  violent  nausea  and  vomiting  that 
the  physician  felt  called  upon  to  bring  on 
abortion  to  save  the  patient's  life,  as  he  sup- 
posed. 

Here  let  me  give  you  one  rule  which  I  have 
always  followed  and  which — although  I  have 
practiced  medicine  for  thirty-five  years,  and 
naturally  have  some  confidence  in  my  own 
judgment— I  still  follow  at  the  present  time. 
This  rule  is,  Nemr  induce  an  abortion  without 
first  having  a   consultation.      You  may  per- 


ABORTION  AND  ITS  TREATMENT.  99 

haps  ask  me  why.  Remember,  in  the  first 
place,  that  a  human  life  depends  upon  your 
decision.  It  is  better,  therefore,  that  the  re- 
sponsibility should  be  shared.  He  who  can 
take  a  human  life  into  his  hands  without  a 
desire  to  thus  have  the  responsibility  divided 
is  not,  in  my  opinion,  a  man  of  proper  feeling. 

If  the  physician  whom  you  consult  does  not 
agree  with  you  that  abortion  should  be  pro- 
duced, the  pregnancy  may  be  allowed  to  go 
on ;  but  if  he  does  agree  with  you  on  this 
point,  your  position  is  naturally  very  greatly 
strengthened.  Such  a  course  as  I  have  recom- 
mended is  in  the  interest  both  of  the  patient 
and  of  the  medical  attendant. 

Let  us  next  inquire  what  are  the  indications 
for  the  artificial  induction  of  abortion.  In  a 
general  way,  it  may  be  stated  that  whenever  it 
is  felt  that  the  prolongation  of  pregnancy  is 
going  to  destroy  the  life  or  intellect,  or  to  per- 
manently ruin  the  health  of  a  patient,  abor- 
tion should  be  brought  on.  It  is  a  well  known 
fact,  for  instance,  that  a  large  number  of  pa- 


100  ABORTION  AND  ITS  TREATMENT. 

tients  die  every  year  from  tlie  vomiting  of 
pregnancy.  It  was  to  this  condition  that  the 
gifted  Charlotte  Bronte,  who  married  some- 
what late  in  life  and  who  was  believed  to  be 
suffering  from  acute  gastritis,  unfortunately  fell 
a  victim.  As  I  have  indicated,  you  will  have 
to  be  on  your  guard  against  deception.  Many 
women  will  either  use  drugs  to  produce  vomit- 
ing, or  else  they  will  suffer  from  nausea  only 
when  the  physician  is  in  the  room.  Such 
women  generally  influence  their  husbands  at 
will,  and  you  must  get  the  evidence  of  a  trust- 
worthy nurse,  or  of  friends  who  are  not  under 
the  influence  of  the  i)atient.  Then,  again,  the 
general  character  of  the  vomiting,  and  the  con- 
dition of  the  patient,  will  assist  you  in  deciding 
whether  her  sufferings  are  real  or  not.  When 
you  find  that  the  obstinate  vomiting  is  a  reality, 
and  it  seems  probable  that  the  woman  will  die 
if  she  is  not  relieved,  it  will  be  nothing  less 
than  criminal  not  to  bring  on  abortion.  In 
such  cases  it  is  astonishing  to  see  how  quickly 
the  symptoms  are  relieved  and  the  patient  be- 


ABORTION   AND   ITS  TREATMENT.  IQl 

gins  to  improve  in  every  way,  when  the  uterus 
has  once  been  emptied  of  its  contents. 

But  there  are  other  conditions  besides  un- 
controllable vomiting  which  call  for  artificial 
abortion.  There  is  some  peculiar  influence  over 
the  kidneys  exercised  by  puerperality,  the  na- 
ture of  which  we  do  not  know.  It  is  a  fact, 
however,  that  a  great  many  women  die  annu- 
ally of  puerperal  nephritis.  As  a  rule,  such 
nephritis  does  not  begin  until  after  the  fourth 
month,  but  in  exceptional  cases  it  occurs  even 
earlier  than  this ;  or,  possibly,  the  patient  may 
have  had  desquamative  nephritis  before  the  com- 
mencement of  pregnancy.  I  can  not  but  regard 
it  as  cruel  to  allow  a  patient  with  marked  symp- 
toms of  this  affection  to  go  on  in  utero-gestation, 
with  the  imminent  risk  of  dying  in  labor  of 
puerperal  convulsions,  or,  if  she  does  not  die 
then,  of  being  doomed  to  chronic  Bright' s  dis- 
ease with  its  attendant  suffering  and  dangers. 

In  the  next  place,  if  you  have  a  pregnant 
patient  with  cardiac  disease  of  such  a  charac- 
ter that  you  think  her  life  is  in  danger,  it  is 


102  ABORTION  AND  ITS  TREATMENT. 

your  duty  to  induce  abortion.  If  she  should 
have  cancer,  or  be  in  the  third  stage  of  phthisis, 
you  should  not  do  this,  because,  in  the  first 
class  of  cases,  you  have  two  lives  to  consider, 
as  the  woman  may  have  a  long  life  before  her, 
while  in  the  last  it  is  impossible  that  she  should 
live  under  any  circumstances. 

The  fourth  condition  which  I  would  men- 
tion is  chorea.  In  one  case  only  in  my  expe- 
rience have  I  had  to  induce  abortion  on  account 
of  this  affection.  The  trouble  was  so  violent 
that  I  feared  the  patient  would  die  before  the 
end  of  gestation,  and  I  therefore  brought  on 
abortion  at  the  end  of  the  fourth  month. 

Fifth,  when  the  pelvic  diameters  are  very 
much  contracted,  so  as  to  render  delivery  at 
full  term  absolutely  impossible,  the  uterus 
should  be  prematurely  emptied. 

While  acknowledging  the  improvements  that 
are  constantly  being  made  in  the  management 
of  the  Csesarean  section,  Porro's  operation,  and 
similar  procedures,  I  still  do  not  believe  that, 
when  we  can  avoid  it  by  inducing  abortion,  we 


ABORTION  AND  ITS  TREATMENT,  103 

are  justified  in  subjecting  our  patient  to  the 
great  risk  attending  these  operations  even  under 
the  most  favorable  conditions. 

Sixth,  in  case  of  violent  convulsions  from  any 
cause  whatever,  abortion  is  indicated.  It  makes 
no  difference  whether  the  convulsions  are  choreic, 
ursemic,  epileptic,  or  of  any  other  character  ex- 
cept hysterical.  Even  if  you  succeed  in  control- 
ling the  seizures  for  the  time  being,  it  is  entirely 
improbable  that  the  woman  can  go  on  for  five 
months,  or  more,  longer  without  a  return  of  the 
trouble,  and  most  likely  in  a  form  so  aggra- 
vated that  death  will  inevitably  result. 

Seventh,  artificial  abortion  is  called  for 
sometimes  on  account  of  uncontrollable  uterine 
haemorrhage.  Placenta  praivia  is  a  condition 
which  does  not  occur  at  the  early  period  of 
pregnancy  which  we  are  now  considering,  and 
the  haemorrhage  to  which  I  refer  is  occasioned 
by  the  separation  and  sliding  away  of  the  de- 
cidua  reflexa  from  the  decidua  vera.  After 
styptics  and  the  tampon  have  been  given  a 
thorough  trial,  and  the  trouble  still  continues, 


104  ABORTION  AND  ITS  TREATMENT. 

there  is  nothing  left  for  us  but  to  bring  on 
abortion ;  for,  if  this  is  not  done,  the  most  seri- 
ous results  will  almost  certainly  ensue. 

In  this  enumeration  I  do  not  pretend  to  give 
you  all  the  conditions  which  may  from  time  to 
time  call  for  this  measure.  I  only  aim  to  show 
you  some  of  the  principal  ones,  as  they  have 
been  met  with  by  me  in  actual  practice,  and  to 
point  out  to  you  the  general  principles  which 
should  guide  you  in  deciding  whether  in  any 
case  of  serious  difficulty  that  presents  itself  you 
ought  to  resort  to  artificial  abortion. 

The  next  step  naturally  is  to  consider  the 
methods  by  which  abortion  is  brought  on  ;  and 
the  procedures  which  I  mention  first  I  only  refer 
to  in  order  that  you  may  carefully  avoid  them. 
The  first  method  is  to  introduce  a  metallic  sound 
into  the  os  uteri,  and  push  it  forcibly  through 
the  foetal  shell.  If  there  be  a  brutal  and  stupid 
method  of  inducing  abortion,  it  is  certainly  this. 
Yet  it  is  done  every  day,  and  is  the  one  com- 
monly practiced  in  criminal  abortions.  There  is 
no  doubt  whatever  about  its  killing  the  foetus, 


ABORTION  AND   ITS   TREATMENT.  105 

but,  after  the  latter  lias  been  killed,  its  dead 
body  is  left  to  rot  in  its  shroud.  You  must 
understand  that  when  I  call  this  procedure  bru- 
tal I  do  not  mean  that  it  is  brutal  to  the  patient 
at  the  time,  for  she  experiences  no  pain  what- 
ever from  the  piercing  of  the  foetal  shell ;  but 
that  it  is  brutal  in  its  results,  since  the  fcetus 
may  remain  in  the  uterus  for  three  months,  oi 
longer,  and  during  all  this  time  its  presence 
there  is  attended  with  the  most  imminent  risk 
of  putrefaction  and  septicaemia. 

The  second  method  is  to  take  a  tent  of 
sponge,  sea-tangle,  or  tupelo,  and,  by  introduc- 
ing it  into  the  os  internum,  cause  dilatation  of 
the  cervical  canal,  and  thus  excite  the  uterus 
to  contract  and  bear  down  upon  its  contents. 
This  is  perhaps  a  little  less  brutal  than  the 
other,  but  only  slightly  so.  It  is  impossible 
to  prevent  the  entrance  of  bacteria  in  the 
use  of  any  kind  of  tent  whatever.  Not  long 
since  my  colleague.  Dr.  Chambers,  had  some 
sea-tangle  tents  prepared  with  every  antiseptic 
precaution,  but,  notwithstanding  this,  they  were 


106  ABORTION  AND  ITS  TREATMENT. 

afterward    found    to    teem  with    bacterial  life 
under  the  microscope. 

Let  me  here  digress  a  moment  to  say  a  word 
in  regard  to  sponge  tents.  I  never  use  them 
now  under  any  circumstances  whatever,  and 
regard  them  only  as  something  connected  with 
ancient  history.  They  have  been  superseded 
by  other  and  better  devices,  Just  as  the  stage- 
coach and  whale-oil  have  been  superseded  by 
the  railway  and  by  gas  and  the  electric  light. 
The  stage-coach  and  the  oil  answered  well 
enough  as  long  as  we  had  nothing  better ; 
and  just  so  it  has  been  with  the  sponge  tent. 
At  the  present  day  these  tents  ought  not 
to  be  used  in  puerperal  conditions,  and  in- 
deed, I  think,  not  even  in  non-puerperal  con- 
ditions. I  have  seen  several  deaths  due  to 
this  cause.  Now,  mark  you,  I  myself  have 
employed  them  up  to  two  or  three  years 
ago  ;  but  formerly  I  also  used  to  travel  by 
the  stage  -  coach  and  read  by  the  oil  -  lamp. 
I  no  longer  use  tents  of  any  kind,  however, 
because  there  are  much  better  and  safer  means 


ABORTION  AND  ITS  TREATMENT.  107 

at  hand  for  accomplishing  the  same  pur- 
pose. 

The  third  method  is  to  take  some  instru- 
ment like  the  uterine  sound  and,  slipping  it 
carefully  up  into  the  uterus  and  along  its 
wall,  gradually  separate  the  decidua  rejiexa 
from  the  decidua  vera.  There  is  not  a  great 
deal  of  danger  connected  with  this  procedure, 
and  it  is  the  only  one  of  these  defective  meth- 
ods of  inducing  abortion  that  I  would  advise 
you  to  adopt  under  any  circumstances  what- 
ever. It  is  much  less  objectionable  than  the 
others,  because  when  you  have  thus  separated 
the  two  membranes  from  each  other  you  still 
have  a  living  foetus  left,  and  at  the  same 
time  your  manoeuvre  has  excited  uterine  con- 
tractions which  wdll  ordinarily  result  in  its 
expulsion.  Still,  I  would  not  make  use  of 
this  method  myself. 

Next,  I  may  mention,  in  passing,  the  use  of 
certain  drugs,  such  as  ergot,  savin,  pennyroyal, 
viscum  album,  or  mistletoe,  and  the  root  of 
the  cotton-plant.      These  are  things  which  the 


108  ABORTION  AND  ITS  TREATMENT. 

charlatan  might  resort  to,  and  which  are  com- 
monly employed  by  ignorant  women ;  but  no 
scientific  physician  would  ever  think  of  placing 
any  dependence  upon  them  whatever.  The  ef- 
fect of  such  drugs  is  to  excite  the  uterus  to 
tetanic  spasms  while  the  os  is  undilated  and 
the  whole  organ  totally  unprepared  to  perform 
the  work  which  is  expected  of  it.  To  make  use 
of  them  is  like  driving  a  spirited  horse  up  to  a 
closed  gate,  and  still  urging  him  to  go  on  when 
there  is  no  way  to  get  through  it. 

Now,  having  spoken  in  this  disparaging  way 
of  the  various  methods  commonly  in  vogue, 
you  will  naturally  expect  me  to  show  you 
some  better  way  ;  and  this  I  will  try  to  do. 
These  are  the  methods  which  have  come  down 
to  us  from  the  past ;  the  one  to  which  I  will 
next  call  your  attention  is  of  modern  origin, 
and  entirely  in  accord  with  the  best  scientific 
teaching  of  the  day,  as  regards  the  all-impor- 
tant matter  of  antisepsis. 

Let  us  suppose  that  you  have  a  patient  at 
the  end   of  the   third  month  of   pregnancy  in 


ABORTION  AND  ITS  TREATMENT.  109 

whom  exist  conditions  which,  in  your  opinion, 
call  for  the  immediate  induction  of  abortion, 
and  that  the  physician  whom  you  have  called 
in  consultation  agrees  with  you  as  to  the  pro- 
priety of  this  procedure.  It  is  important  that 
the  abortion  should  be  brought  on  promptly. 
How  shall  you  set  about  it  ?  In  this  way. 
Anaesthetize  the  patient  with  ether,  not  chloro- 
forai,  and  place  her  on  a  table  in  the  Sims 
position.  The  vagina,  vulva,  and  anus  having 
been  thoroughly  cleansed  with  carbolized  water, 
take  a  sponge  saturated  with  bichloride  solu- 
tion (1  to  2,000),  and  with  it  fill  the  vagina  with 
the  solution.  By  this  means  the  os  will  be 
placed  in  a  lake  of  the  antiseptic  fluid.  But 
may  not  the  bichloride  poison  the  patient  ? 
Well,  I  have  never  yet  met  with  this  accident ; 
but,  even  if  the  mercury  should  affect  her 
system  to  some  extent,  the  dose  will  not  be 
sufficient  to  kill  her,  and  it  is  better  to  run 
this  slight  risk  rather  than  expose  her  to  the 
danger  of  septic  infection. 

Next  you  catch  the  cervix  with  a  little  te- 


110  ABORTION  AXD  ITS  TREATMENT. 

naculum  and  dip  it  below  the  surface  of  the  bi- 
chloride solution.  You  will  thus  perceive  that 
this  is  a  subaqueous  operation,  and  on  that 
account  it  is  as  free  from  the  risk  of  being  at- 
tended with  untoward  results  as  it  is  possible 
to  make  it.  With  a  divulsor  of  small  size  you 
stretch  the  cervical  canal  as  far  as  you  can  in 
all  directions.  About  three  minutes  is  taken  up 
with  this  procedure,  and  you  then  introduce  a 
larger  divulsor  and  stretch  the  canal  still  further. 
If  it  is  at  the  end  of  the  third  month,  and  the 
divulsion  has  been  successful,  you  can  now  carry 
your  finger  through  the  cervix.  You  next  in- 
troduce a  glass  plug,  of  larger  or  smaller  size, 
according  to  circumstances,  such  as  I  show 
you  here,  and  which  is  as  large  as  the  index 
or  the  little  finger,  as  the  case  may  require. 
Having  gotten  this  well  up  into  the  cervix,  yoa 
pack  the  vagina  with  iodoform  gauze,  and  then 
apply  a  tampon  in  the  manner  already  described 
to  you.  This  is  all  you  have  to  do ;  and,  having 
done  it,  you  can  go  home  and  leave  the  case 
to  nature. 


ABORTION  AND  ITS  TREATMENT.  m 

Within  twelve  hours  the  woman  will  proba- 
bly have  pain,  and  this  is  the  first  symptom 
of  abortion  under  these  circumstances.  Very 
likely  she  will  then  vomit,  and  this  is  the  sec- 
ond symptom.  Finally,  a  little  blood  will 
probably  ooze  through  the  tampon,  and  this  is 
the  third  symptom. 

The  plug  and  the  tampon  may  be  left  in 
position  for  from  thirty- six  to  forty-eight  hours. 
When  you  remove  them  you  can,  if  necessary, 
stretch  the  os  again,  and  put  in  a  larger  plug, 
sustaining  it  with  iodoform  gauze,  as  in  the  case 
of  the  first  one.  You  need  not  be  anxious  to 
hurry  the  labor-pains.  They  will  come  on  fast 
enough,  and  the  plug  will  probably  be  at  last 
forced  out  by  the  contractions  of  the  uterus. 
Behind  it  will  come  the  product  of  conception, 
and  then  the  whole  thing  will  be  over.  This  is 
all  that  I  ever  do  now  in  these  cases  of  artificial 
abortion,  and  I  am  satisfied  that  you  will  get 
good  results  with  this  method  when  you  come 
to  practice  it.  I  know  also  that  you  will 
avoid  the  bad  results  that  are  so  apt  to  fol- 

8 


112  ABORTION  AND  ITS  TREATMENT. 

low  the  old  methods  which  I  have  mentioned 
to  yon. 

I  did  not  mention  to  you  that  the  plug  to 
which  I  have  made  allusion  is  about  an  inch 
and  a  half  in  length,  and  provided  with  a  broad 
shoulder,  which  prevents  its  entrance  into  the 
uterine  cavity,  while  the  tampon  keeps  it  per- 
fectly in  position  in  the  cervical  canal.  The 
following  figure  represents  its  shape  and  me- 
dium size. 


Where  the  case  is  quite  urgent,  I  never  hesi- 
tate to  use  the  divulsor,  and  with  forceps  or 
large  curette  at  once  to  remove  the  entire  fa3tal 
shell.  I  have  done  this  about  a  dozen  times  I 
think,  and  so  far  have  had  no  bad  result  from 
the  practice. 

THE   END. 


THE 

NEW   YORK   MEDICAL  JOURNAL 

A  WEEKLY  REVIEW  OF  MEDICINE. 

EDITED    BY 

FRANK  P.  FOSTER,  M.  D. 


■yHE  PHYSICIAN  who  would  keep  abreast  with  the  advances  in  medical 
science  must  read  a  live  weekly  medical  journal,  in  which  scientific  facts 
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this  feature,  so  utterly  ignored  by  the  "  average  "  medical  periodical. 

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PUBLISHED  BY 

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t/t  New,  Thoroughly  Revised,  and  Enlarged  Edition  of 

Ouain's  Dictionary  of  Medicine. 

BY   VARIOUS   WRITMRS. 

EDITED    BY 

Sir  RICHARD   QUAIN,   Bart,  M.  D.,  LL.  D.,  etc., 

Physician  Extraordinary  to  Her  Majesty  the  Queen ;    Consulting  Physician  to   the 
Hospital  for  Diseases  of  the  Chest,  Brompton,  etc. 

Assisted  by  FREDERICK   THOMAS    ROBERTS,  M.  D.,  B.  Sc, 
Fellow  of  the  Royal  College  of  Physicians,  etc. ; 

And  J.   MITCHELL    BRUCE,  M.  A.,  M.  D., 
Fellow  of  the  Royal  College  of  Physicians,  etc. 

WITH   AN   AMERICAN   APPENDIX 

By  SAMUEL  TREAT  ARMSTRONG,  Ph.  D.,  M.  D., 
Visiting  Physician  to  the  Harlem,  VVillard  Parker,  and  Riverside  Hospitals,  New  York. 


IN    TWO    VOLUMES.  Sold  only  by  subscription. 

This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are 
fully  discussed  in  alphabetical  order.  The  description  of  each  includes  an  account  of 
its  etiology  and  anatomical  characters;  its  symptoms,  course,  duration,  and  termi- 
nation; its  diagnosis,  prognosis,  and,  lastly,  its  treatment.  General  Pathology  com- 
prehends articles  on  the  origin,  characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies,  their 
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of  Hygiene  treat  of  the  causes  and  prevention  of  disease,  of  the  agencies  and  laws 
affecting  public  health,  of  the  means  of  preserving  the  health  of  the  individual,  of  the 
construction  and  management  of  hospitals,  and  of  the  nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  re- 
spective headings,  both  in  aggregate  and  in  detail. 

The  American  Appendix  gives  more  definite  information  regarding  American 
Mineral  Springs,  and  adds  one  or  two  articles  on  particularly  American  topics,  besides 
introducing  some  recent  medical  terms  and  a  few  cross-references. 

The  British  Medical  yournal  says  of  the  new  edition  : 

"  The  original  purpose  which  actuated  the  preparation  of  the  original  edition  was, 
to  tjuote  the  words  of  the  preface  which  the  editor  has  wiitten  for  the  new  edition,  'a 
desire  to  plac'3  in  the  hands  of  the  practitioner,  the  teacher,  and  the  student  a  rnean« 
of  ready  reference  to  the  accumulated  knowledge  which  we  possessed  of  scientific  and 
practical  medicine,  rapid  as  was  its  progress  and  difficult  of  access  as  were  its  scat- 
tered records. '  The  scheme  of  the  work  was  so  comprehensive,  the  selection  of  writt  rs 
so  judicious,  that  this  end  was  attained  more  completely  than  the  most  sanguine  ex- 
pectations of  the  able  editor  and  his  assist^tnts  couM  have  anticipated.  ...  In  pre- 
paring a  new  edition  the  fact  had  to  be  faced  that  never  in  the  history  of  medicine  h.nd 
progress  been  so  rapid  as  in  the  last  twelve  ye.irs.  New  facts  have  been  ascertained, 
and  new  ways  of  looking  at  old  facts  have  come  to  be  rec<ignized  as  true.  ._  .  .  The 
revision  which  the  work  has  undergone  has  been  of  tlie  most  thorough  and  judicious 
ch.aracter.  .  .  .  The  list  of  new  writers  numbe-s  fifty,  and  among  them  are  to  be  found 
the  names  of  those  who  are  leading  authorities  upon  the  subjects  which  have  been  com- 
mitted to  their  care."  

New  York:   D.  APPLETON   &   CO.,  72  Fifth  Avenue. 


THE  SCIENCE  AND 
ART  OF   MIDWIFERY. 

By  William  Thompson  Lusk,  M.  A.,  M.  D., 

Trofessor  of  Obstetrics  and  T)iseases  of  IVomen  and  Children  in  the 

'Bellevue  Hospital  Medical  College;    Obstetric  Surgeon  to  the 

Maternity  and  Emergency  Hospitals  ;  and  Gyncecologist 

to  the  Bellevue  Hospital. 


FOURTH    EDITION.     REVISED   AND    REWRITTEN. 
With  246  Illustrations. 

8vo.     Cloth,  $^.00 ;  sheep,  ^6.00. 

"  It  was  the  pleasure  of  the  undersigned  to  write  a  review  of  this  most 
excellent  and  masterly  work  on  obstetrics  when  it  appeared  in  its  first  edition. 
The  present  is  the  fourth,  an  edition  enlarged  and  revised.  It  is  a  model  of 
recent  medical  literature  in  obstetrics,  and  can  not  but  give  great  credit  to 
the  author  and  to  American  medicine.  Model  it  is  of  clear,  forcible,  and 
beautiful  English,  of  good  arrangement  of  subject-matter,  and  of  thorough- 
ness of  modern  obstetric  exposition.  The  changes  which  have  taken  place 
in  the  theory  and  practice  of  obstetrics  since  the  issue  of  the  last  edition 
have  made  it  necessary  for  the  author  to  present  to  the  profession  what  is 
essentially  a  new  book.  Most  cheerfully  will  we  recommend  to  the  students 
of  medicine  a  study  of  Lusk.  It  ranks  well  with  Playfair,  and  is  second  to 
no  book  in  our  language."— Chauncey  D.  Palmer,  in  the  Ohio  Medical 
Journal. 

"  The  book  is  now  beyond  criticism,  for  it  has  been  accepted  by  the  un- 
erring judgment  of  the  great  body  of  physicians.  We  congratulate  Dr.  Lusk 
upon  this  reward  for  the  immense  labor  he  has  bestowed  upon  it." — New 
York  Medical  Journal. 

"  It  contains  one  of  the  best  expositions  of  the  obstetric  science  and  prac- 
tice of  the  day  with  which  we  are  acquainted.  Throughout  the  work  the 
author  shows  an  intimate  acquaintance  with  the  literature  of  obstetrics,  and 
gives  evidence  of  large  practical  experience,  great  discrimination,  and  sound 
judgment.  We  heartily  recommend  the  book  as  a  full  and  clear  exposition 
of  obstetric  science,  and  safe  guide  to  student  and  practitioner.'' — London 
Lancet. 

"  It  is  but  a  short  time  since  we  had  occasion  to  review  this  work,  of 
which  we  were  enabled  to  speak  in  the  highest  terms  of  praise.  The  rapid 
advance  of  many  departments  of  obstetrics  has  meantime  called  for  a  few 
additions.  These  having  been  made,  it  can  be  confidently  said  that  Lusk's 
Midwifery  holds  a  high  place  among  American  authors,  and  deserves  to  be 
extensively  employed  for  reference,  and  recommended  to  students  as  a  re- 
liable and  unusually  readable  text-book. "— Cawarfa  Medical  and  Surgical 
Journal. 

Kew  York:  D,  APPLETON    &   CO.,  Publishers,  72  Filth  Avenue. 


MONTHLY  NURSING, 


By  A.  WORCESTER,  A.  M.,  M.  D., 

Fellow  of  the  Massachusetts  Medical  Society ;  Physician  to  the 
Waltham  Hospital. 

SECOND     EDITION. 


12mo,  250  pages.     Cloth,  $1.25. 


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of  its  kind,  and  it  is  a  pity  that  its  scope  is  limited,  as  its  name 
implies,  to  obstetric  nursing.  .  .  .  The  book  is  issued  in  a  neat  and 
attractive  style,  and  contains  many  practical  hints  which  would  not 
come  amiss  to  the  physician,  which  he  would  not  otherwise  learn, 
except  through  experience." — Weekly  Medical  Review. 

"This  is  one  of  the  most  practical  little  books  we  have  seen. 
Not  only  does  it  reveal  the  duties  of  the  nurse,  but  it  contains  an 
amount  of  useful  details  that  will  be  invaluable  to  the  young  prac- 
titioner."— Practice. 

"...  We  regard  this  book  as  of  great  importance,  and  doctors 
should  insist  upon  their  monthly  nurses  adopting  it  as  a  text-book 
for  constant  bedside  use." — Virginia  Medical  Monthly. 

"  This  little  volume  is  one  of  the  most  complete  treatises  of  the 
kind  we  have  seen.  Mothers  and  nurses  will  find  it  invaluable." — 
New  York  Medical  Times. 


New  York:  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


A  MANUAL  OF  INSTRUCTION 

IN  THE   PRINCIPLES  OF 

Prompt  Aid  to  the  Injured. 

INCLUDING  A  CHAPTER  ON  HYGIENE,  AND  THE  DRILL 

REGULATIONS  FOR  THE  HOSPITAL  CORPS,  U.  S.  A. 

DESIGNED  FOR  MILITARY  AND  CIVIL  USE. 

By  ALVAS   H.    DOTY,  M.D., 

Major  and  Surgeon,  Ninth  Regiment,  N.  G.  S.  N.  Y. ;  Attending  Surgeon  to 
Bellevue  Hospital  Dispensary,  New  Yorli. 

SECOND  EDITION,  BEVISED  AND  ENLARGED. 

ISmo.    304  pages,  with  134  Illustrations.    Cloth,  S1.50. 

This  book  is  intended  to  impart  the  knowledge  necessary  for  the  prompt 
and  intelligent  care  of  persons  suffering  from  haemorrhage,  fractures,  dislo- 
cations, wounds,  contusions,  burns,  shocks,  sprains,  poisoning,  the  efi'ects 
of  heat  or  cold,  apoplexy,  epilepsy,  those  rescued  from  the  water,  and  other 
accidents  which  are  liable  to  occur  at  any  time,  the  results  of  which  may  be 
materially  influenced  by  the  care  and  attention  which  the  sufferer  receives  at 
the  outset. 

The  book  is  of  a  size  convenient  for  the  pocket,  and  embraces  a  greater 
range  of  subjects  than  is  found  in  any  work  of  the  kind  heretofore  pub- 
lished ;  and  its  completeness  and  simplicity  commend  it  to  the  general  public 
as  well  as  to  that  portion  which  forms  the  militia  of  the  States  of  the  Union. 

"...  This  is  the  most  satisfactory  little  monograph  on  this  subject  with  which 
we  are  familiar.  It  is  enriched  by  numerous  illustrations,  taken,  with  due  credit, 
largely  from  the  works  of  Esmarch,  Flint,  and  others.  In  addition  to  the  usual 
matter  contained  in  such  little  works,  a  chapter  on  Hygiene  has  been  introduced, 
and  also  one  containing  the  recently  adopted  drill  regulations  of  the  ambulance 
corps  of  the  United  States  Army."— Columbus  Medical  Journal. 

"...  This  book  should  be  In  every  physician's  office.  This  edition  will  sus- 
tain the  reputation  acquired  by  its  predecessor  in  every  respect,  and  the  work  is 
likely  to  have  a  wide  field  of  usefulness." — Charlotte  Medical  Journal. 

"...  It  is  a  manual  written  in  plain,  clear  style.  It  would  be  of  value  in  the 
hands  of  the  police  of  large  cities.  The  instructions  are  good,  and  particularly 
those  of  the  chapter  on  Haemorrhage.  The  chapter  on  Hygiene  is  a  desirable  addi- 
tion."— Medical  Standard. 

".  .  .  It  is  the  best  book  that  the  layman,  hospital  assistant,  or  nurse  can  get, 
and  it  is  a  most  excellent  work  for  the  medical  man  also.  To  be  pointed  in  our 
opinion,  we  say  unhesitatingly  it  is  the  best  book  of  its  kind  we  have  ever  seen." 
—Southern  Clinic. 

"...  To  the  ambulance  corps  connected  with  the  different  military  organiza- 
tions it  will  be  especially  valuable  ;  and  not  less  so  to  all  those  who  may  at  any 
time  be  benefited  by  the  knowledge  or  application  of  its  excellent  precepts  and 
practical  sxxggesixons.''''— College  and  Clinical  Record. 

"  .  .  .  The  author  seems  to  have  succeeded  remarkably  well  in  the  difficult  task 
of  giving  to  nonmedical  persons  information  which  will  properly  instruct  them 
to  cope  with  emergencies  without  encouraging  them  to  usurp  the  functions  of  the 
physician  or  sxageou.''— Charleston  Sunday  News. 


New  York:   D.  APPLETON  &  CO.,  73  Fifth  Avenue. 


A  TEXT-BOOK  ON 
THE    DISEASES    OF   WOMEN. 

By  ALEXANDER  J.  C.  SKENE,  M.  D., 

Professor  of  Gynaecology  in  the  Long  Island  College  Hospital,  Brooklj-n,  N.  Y., 

formerly  Professor  of  Gynaecology  in  the  New  York  Post-Graduate 

Medical  School  and  Hospital,  etc. 

With  Two  Hundred  and  Fifty-four  IlluBtTations,  of  which  One  Hundred  and 
Sixty-five  are  Original  and  Nine  Chromolithographs. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

SOLD  BY  SUBSCRIPTION  ONLY. 


This  treatise  is  the  outconiBsand  rcRresents  the  experience  of  a  long 
and  active  professional  life,  the  giKat(?r  part  of  which  has  been  spent  in 
the  treatment  of  the  diseases  of  wootbd.  It  is  especially  adapted  to  meet 
the  wants  of  the  general  practitioner  in  recognizing  this  class  of  diseases 
as  he  meets  them  in  every-day  practice  and  in  treating  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in  their 
natural  order,  and  thus  more  easily  comprehended  and  remembered  by 
the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in  his 
practice,  and  it  has  been  his  endeavor  to  so  describe  the  operative  pro- 
cedures adopted  by  him,  even  to  their  minutest  details,  as  to  make  his 
treatise  a  practical  guide  to  the  gynaecologist. 

Although  all  the  subjects  which  are  discussed  in  the  various  text- 
books on  gynaecology  have  been  treated  by  the  author,  it  has  been  a 
prominent  feature  in  his  plan  to  consider  also  those  which  are  but  inci- 
dentally, or  not  at  all,  mentioned  in  the  text-books  hitherto  published, 
and  yet  which  are  constantly  presenting  themselves  to  the  practitioner 
for  diagnosis  and  treatment. 

The  illustrations  are  mostly  entirely  new,  and  have  been  speciallv 
made  for  this  work.  The  drawings  are  from  nature,  or  from  wax  and 
clay  models  from  nature,  and  have  been  reproduced  by  processes  best 
adapted  to  represent  in  the  most  truthful  and  permanent  forms  the  exact 
appearances  of  the  diseased  organs,  methods  of  operation,  or  instrument? 
which  they  are  designed  to  illustrate. 

Wherever  it  has  been  possible  to  make  clearer  the  author's  methods 
of  treatment  by  histories  of  cases  which  have  actually  occurred  in  his 
practice,  this  has  been  done.  A  simple,  typical  case,  such  as  is  ordi- 
narily met  with,  is  first  described,  and  then  difficult  and  obscure  cases, 
with  the  various  complications  which  occur. 

New  York:  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


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THE  LIBRARY 
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STAMPED  BELOW. 


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